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THE    SURGICAL    TREATMENT    OF    FACIAL 
NEURALGIA. 


THE  SURGICAL  TREATMENT  OF 
FACIAL   NEURALGIA 


BY 


J.   HUTCHINSON,  Jun.,  F.R.C.S. 

Surgeon  to  the  London  Hospital  ; 
Examiner  in  Surgery,  Royal  Army   Medical  Department 


NEW    YORK 
WILLIAM    WOOD   AND   COMPANY 
MDCCCCV 


TO    MY    FATHER 


PREFATORY  NOTE. 

Reference  to  the  list  of  published  writings  on 
the  subject  which  is  given  at  the  end  of  this  work 
will  prove  how  numerous,  yet  how  widely  scattered 
they  are.  Professor  Krause's  valuable  monograph, 
published  in  1896,  is,  however,  the  only  one  which 
gives  at  all  a  complete  review,  and  it  is  largely 
occupied  with  questions  relating  to  the  physiology 
of  the  fifth  nerve.  I  have  only  briefly  discussed 
these  points,  with  the  view  of  confining  the  present 
account  to  practical  details.  Considerable  differ- 
ence of  opinion  still  exists  as  to  the  best  forms 
of  operation  for  facial  neuralgia.  The  hope  of 
providing  a  clear  account  of  a  complex  and  difficult 
subject,  and  of  making  it  more  simple  is  the  chief 
reason  for  this  work. 

J.   Hutchinson. 

I,  Park  Crescent, 

Portland  Place,    W. 


CONTENTS. 


Chapter    I. 

PAGE 

The  Causes  and  Forms  of  Facial  Neuralgia     i 


Chapter  II. 
Epileptiform  Neuralgia  ;  its  Course  and  Symptoms    ...         17 

Chapter  III. 
The  Nature  and  Pathology  of  Epileptiform  Neuralgia  26 

Chapter  IV. 
The  Treatment  of  Epileptiform  Neuralgia       ...         ...         39 

Chapter  V. 
Operations  on  the  Gasserian  Ganglion  ...         ...         ...         75 

Chapter  VI. 

Excision    of    the   Gasserian    Ganglion.      Results  and 

Complications  of  the  Operation       ...         ...         ...       103 

Reference  to  published  papers  on  the  Surgical  Treat- 
ment of  Trigeminal  Neuralgia         ...         ...         ...       131 

Index  ...         ...         ...  ..         ...       137 


THE 

SURGICAL    TREATMENT    OF 
FACIAL    NEURALGIA. 

CHAPTER    I. 

Tii-E 'Causes  and  Forms  of  Facial  Neuralgia. 

-■  -■^■c;-,!^!\^?■ 
THE  subject  of  facial  or  trigeminal  neuralgia  in- 
cludes some  of  the  most  interesting  problems  in  the 
whole  realm  of  pathology  and  physiology.  The  sur- 
geon, however,  is  chiefly  concerned  with  the  ques- 
tion :  "  What  cases  of  neuralgia  are  suited  for  opera- 
tive treatment,  and  what  are  the  best  methods  to 
employ?"  The  answer,  obviously,  should  depend 
upon,  a  scientific  classification,  based  solely  upon  the 
causes  of  neuralgia  ;  at  present  such  a  classification 
is  impossible.  We  can  distinguish  the  pain  due  to 
errors  of  refraction  from  the  more  intense  neuralgia 
set  up  by  a  peridental  abscess,  and  the  pain  caused 
by  a  syphilitic  node  of  the  skull  from  that  accom- 
panying an  attack  of  herpes  frontalis. 

Yet,  of  the  gravest  form  of  all,  epileptiform  or 
major  neuralgia  (tic  douloureux),  which  now  fur- 
nishes one  of  the  triumphs  of  surgery,  the  patho- 
logy and  causation  are  practically  unknown.     What 


evidence  exists  on  the  subject  and  what  theories 
have  been  devised  will  be  briefly  discussed  later. 

The  following  rough  classification  may  be  sug- 
gested : — 

(i)  The  neuralgia  due  to  anaemia,  gout,  malaria, 
or  other  abnormal  conditions  of  the  blood. 

(2)  That  due  to  a  neuritis,  e.g.,  the  neuralgia 
accompanying  herpes,  or  tabes  dorsalis. 

(3)  The  pain  referred  from  some  local  cause, 
such  as  a  carious  tooth,  an  inflamed  iris,  a  syphilitic 
node,  &c. 

The  three  forms  of  neuralgia  summarised  have 
definite  causes,  the  removal  of  which  is  the  aim  of 
the  physician  or  surgeon.  For  none  of  them  is  any 
operation  indicated  on  the  nerve-trunks  which  are 
apparently  involved,  though  destruction  of  the 
terminal  twigs  may  be  occasionally  indicated,  as  in 
the  neuralo-ia  due  to  a  hollow  carious  tooth.       More- 

o 

over,  in  these  cases  the  neuralgia  is  favoured  or 
induced  by  certain  known  conditions  ;  it  is  more  or 
less  continuous,  or,  if  spasmodic,  the  patient  has 
intervals  of  only  comparative,  and  not  complete, 
absence  of  pain. 

In  (4)  Epileptiform  neuralgia  (tic  douloureux, 
neuralgia  major),  neither  local  cause  nor  favouring 
conditions  can  as  a  rule  be  assigned  ;  the  intermit- 
tent nature  of  the  pain  is  kept  up  from  first  to  last 
with  shortening  intervals.  In  this  form  of  neuralgia 
any  attempt  of  the  surgeon  to  remove  some  peri- 
pheral exciting  lesion  is  worse  than  useless,  whilst 
an   operation   on  the  central  part  of  the  fifth  nerve 


(the  Gasserian   ganglion)    is  followed  by  complete 
cure. 

Some  other  and  less  definite  kinds  of  neuralgia 
of  the  head  might  be  introduced,  such  as  referred 
pain  from  visceral  causes,  hysterical  neuralgia 
(closely  allied  to  the  preceding),  migraine,  &c., 
but  these  belong  to  the  physician's  rather  than 
to  the  surgeon's  province.  Dr.  Henry  Head, 
F.R.S.,  has  given  a  masterly  account  of  the  whole 
subject  in  Allbutt's  "System  of  Medicine"  (vol.  vi.)» 
and  in  Pepper's  "System  of  Medicine"  (vol.  v.), 
it  is  also  treated  in  a  complete  and  interesting 
manner.  Epileptiform  neuralgia  (neuralgia  major) 
can  as  a  rule  be  easily  distinguished  from  the  other 
forms  after  it  has  become  well  established,  though 
in  its  early  stages  mistakes  are  very  apt  to  be  made. 
Before  discussing  in  detail  its  symptoms  and  treat- 
ment, some  of  the  more  common  varieties  of 
neuralgia  minor  may  be  illustrated. 

The  neuralgia  due  to  eye-strain  from  hyper- 
metropia,  presbyopia,  or  astigmatism,  is  well-known  ; 
it  is  almost  always  frontal  and  ocular  in  distribution, 
and  is  brought  on  by  use  of  the  eyes  in  near  vision. 
Its  relief  by  correcting  the  error  of  refraction  with 
suitable  glasses  is  immediate.  Iritis  and  acute 
glaucoma  are  often  attended  with  more  intense 
neuralgia,  having  much  the  same  distribution. 
The  extreme  importance  of  recognising  the  reflex 
nature  of  the  pain  and  of  instituting  the  proper 
treatment  for  its  cause  cannot  be  over-rated. 


The  neuralgia  from  glaucoma  and  iritis  often 
affects  the  temporal  region,  and,  in  the  former  case, 
the  upper  or  lower  jaw  may  be  the  seat  of  varying 
tenderness  and  pain.^  Such  a  distribution  is  never 
met  with  in  the  neuralgia  due  to  errors  of  refraction. 
It  should  not  be  forgotten  that  the  latter  form  may 
be  aggravated  by  systemic  conditions.  Thus,  it 
may  be  necessary  to  treat  ansemia  as  well  as  hyper- 
metropia,  &c.,  or  the  cure  will  be  imperfect  ;  and 
Dr.  Head  points  out  that  in  some  cases  in  women 
the  climacteric  may  share  with  the  onset  of  pres- 
byopia in  inducing  troublesome  neuralgia. 

Another  important  point  is  that  eye-strain  may 
lead  to  paroxysmal  attacks  of  headache  of  con- 
siderable intensity  accompanied  by  vomiting. 
Many  a  case  of  acute  glaucoma  has  been  diagnosed 
as  one  of  "bilious  headache"  during  the  first  day 
or  two,  until  it  was  too  late  to  save  the  sight  by 
iridectomy. 

It  will  be  noticed  that  the  neuralgia  having  an 
ocular  cause  is  nearly  always  referred  to  the  fore- 
head. True  epileptiform  neuralgia  hardly  ever 
begins  in  the  first  division  of  the  fifth  (see  page 
17).  Herpes  frontalis  is  usually  preceded  by  con- 
siderable pain  in  this  nerve,  and  after  the  eruption 
has  subsided,  neuralgia  may  be  very  persistent, 
lasting  in  the  worst  cases  for  some  months.  It 
always     however     subsides     ultimately,     especially 

^  Head,  loc.  cit.,  p.  746. 


under  careful  treatment.  The  pathology  is  now 
well  established,  largely  owing  to  the  work  of  Dr. 
Henry  Head  ;  there  is  a  definite  inflammation  of 
the  Gasserian  ganglion  or  of  the  ophthalmic  trunk. 

Another  cause  of  severe  frontal  neuralgria  remains 
to  be  noted,  namely,  catarrhal  or  suppurative  in- 
flammation of  the  air  sinuses  in  the  frontal,  ethmoid,' 
or  sphenoid  bones.  It  is  not  merely  distension  of 
the  sinuses  with  pus  which  causes  the  intense  pain, 
for  an  attack  which  clears  up  entirely  may  be 
attended  with  such  severe  throbbinof  neuralg^ia  that 
at  the  time  the  presence  of  pus  may  be  strongly 
suspected.  Influenza  is  a  fertile  source  of  such 
neuralgia,  as  also  of  empyema  of  the  frontal  or  other 
sinuses.  Disease  of  the  antrum  of  Higfhmore 
usually  produces  dull  throbbing  pain  in  the  cheek, 
though  it  may  extend  up  to  the  forehead,  and  in 
neglected  cases  the  whole  trigeminal  area  may  be 
concerned.  The  grave  mistake  may  then  be  made 
of  treating  the  case  as  one  of  neuralgia  alone,  and 
of  ignoring  the  real  cause. 

A  young  and  healthy  officer  became  subject  to  one- 
sided "  facial  neuralgia  "  of  increasing  intensity.  He  was 
then  in  India,  and  was  treated  in  hospital  with  all  kinds 
of  sedative  drugs  without  avail.  Becoming  steadily  worse, 
he  was  invalided  home  to  England.  On  the  voyage  he 
became  hemiplegic,  and  was  landed  in  an  extremely 
exhausted  condition.  For  the  first  time  the  nature  of  his 
disease  was  ascertained,  namely,  suppuration  in  the  antrum 
of  Highmore,  from  which  disease  of  the  bone  had  spread 
up  to  the  base  of  the  skull,  with  consecutive  meningitis 
and  cerebral  abscess.  Operative  measures  were  unfortu- 
nately too  late  to  save  the  patient's  life. 


Cases  such  as  the  above  are  very  exceptional ;  as 
Dr.  Head  remarks,  "  even  in  those  nasal  affections 
that  cause  pain,  it  is  rarely  acute  enough  to  be 
spoken  of  as  neuralgia."  Suppurative  inflammation 
of  the  frontal  sinus,  especially  if  its  infundibular 
exit  is  blocked,  and  the  cavity  becomes  distended 
with  pus,  is  the  most  likely  to  produce  pain  of  a 
high  degree  of  severity. 

Headache  and  neuralgia  due  to  syphilis  are  of 
great  importance,  since  in  most  cases  they  can  be 
cured  or  greatly  relieved  by  mercury  and  iodides  ; 
moreover,  their  cause  is  often  overlooked. 

Their  various  forms  and  the  circumstances  under 
which  they  occur  will  be  best  illustrated  by  the 
following  examples  : — 


I. — Persistent   Cephalalgia  in  the  Secondary  Stage 
from  Neglect  of  Treatment. 

Dr.  G.  Schorstein  and  I  once  examined  a  man  who  was 
claiming  damages  on  account  of  a  contusion  of  the  head, 
which  had  been  followed  by  persistent  and  intense  pain 
with  loss  of  sleep  and  a  torpid  mental  condition.  The 
pain  was  largely  occipital,  with  radiations  down  the 
cervical  spine.  The  headache  was,  as  a  rule,  worse  at 
night,  but  it  never  left  him,  and  his  doctor  had  tried 
various  sedatives  without  giving  any  relief.  He  com- 
plained only  of  this  continuous  ache,  which  had  entirely 
prevented  his  working  for  several  weeks ;  in  fact,  he  was 
confined  to  his  room  and  looked  a  physical  wreck.  There 
was  no  optic  neuritis  or  vomiting,  but  giddiness  if  he 
attempted  to  walk. 


In  making  a  thorough  examination  we  found  a  copious 
blotchy  syphilitic  eruption,  which  had  appeared  within 
three  weeks  of  the  accident.  Six  months  had  elapsed,  but 
no  anti-syphilitic  treatment  of  any  kind  had  been  attempted, 
nor  would  his  doctor  admit  the  diagnosis  of  syphilis.  The 
man,  however,  did  not  get  damages,  but  took  a  mercurial 
course  instead.  It  may  be  noted  that  persistent  headache 
or  neuralgia  occasionally  results  from  head-injury  (cerebral 
concussion),  with  or  without  fracture  of  the  skull,  but  in  this 
case  the  injury  was  certainly  not  the  main  cause. 


II. — Iritis  attributed  to  Injury.     Severe  Neuralgia 
of  Head.     Secondary  Syphilis  Overlooked. 

This  case  bore  a  strong  resemblance  to  the  one  just 
noted.  A  man  working  in  the  Docks  was  struck  by  a 
rope  which  swung  round  his  head.  For  four  months  after 
the  accident  he  attended  Moorfields  Hospital  for  slight 
iritis  in  both  eyes,  and  he  also  was  treated  by  no  fewer  than' 
six  medical  men  in  addition,  on  account  of  severe  head- 
ache. The  neuralgia  was  constant,  but  worse  at  night ;  it 
was  chiefly  frontal  and  vertical.  During  the  four  months 
the  man  was  receiving  compensation  from  the  Dock  Com- 
pany, but  Dr.  Finlay,  its  medical  adviser,  being  dissatis- 
fied, sent  the  patient  up  to  me.  There  was  no  syphilitic 
eruption  present,  nor  could  I  obtain  any  history  of  chancre 
of  the  penis,  but  the  evidence  as  to  syphilis  was  conclusive. 

It  consisted  in  :  (i)  a  well-marked  bald  patch  on  the 
dorsum  of  the  tongue,  with  two  small  ulcers ;  (2)  chronic 
enlargement  of  the  glands  in  the  right  groin  and  on  both 
sides  of  the  neck ;  (3)  uveal  deposit  from  iritis  in  each 
eye ;  and  (4)  the  persistent  cephalalgia  with  characteristic 
nocturnal  exacerbations.  The  man  was  urged  to  take 
a  proper  mercurial  course,  and  I  believe  that  his  symptoms 
entirely  subsided  under  its  influence. 


III. — Headache  due  to  Periostitis  and  Nodes  of  the 
Skull  in  the  Late  Stages  of  Syphilis. 

Many  examples  of  this  could  readily  be  quoted. 
In  some  there  may  be  one  or  more  definite  tender 
swellings  on  the  skull,  accompanied  by  radiating 
pain  ;  in  others  the  distribution  is  more  general,  and 
no  isolated  node  can  be  distinguished.  There  may 
be  sclerosis  of  large  areas  of  bone,  or  a  node 
situated  entirely  within  the  cranium.  Pericranial 
gummata  are  usually  soft  and  free  from  tension,  and 
therefore  cause  little  pain,  but  occasionally  a 
localised  necrosis  occurs  beneath  them.  Should 
an  abscess  then  form  between  dura  mater  and  bone, 
very  severe  cephalalgia  may  be  produced.  Opera- 
tion under  such  circumstances  is  urgently  called  for. 
As  a  rule,  however,  the  symptoms  yield  to  increas- 
ing doses  of  iodides  of  sodium  and  potassium  or  to 
mercurial  inunction. 

Syphilitic  necrosis,  when  it  involves  the  base  of 
the  skull,  may  cause  intense  suffering,  of  which  the 
following  case  is  an  example  : — 

About  ten  years  after  contracting  syphilis,  a  man 
became  the  subject  of  aggressive  necrosis,  which  destroyed 
the  whole  of  the  palate  and  the  nasal  septum.  It  spread 
to  the  turbinated  and  sphenoid  bones,  until  a  chasm  was 
left,  through  which  the  roof  of  the  naso-pharynx  was 
exposed.  The  disease  progressed  in  spite  of  all  kinds  of 
mercurial  and  iodide  treatment,  the  latter  drug  being  the 
more  effective,  but  causing  considerable  depression. 

Piece  by  piece  the  bone  of  the  skull  came  away,  the  separ- 
ation being  attended  with  horrible  pain  which  destroyed 


sleep  for  weeks  together.  The  neuralgia  was  referred  to 
both  temples  and  to  the  forehead,  there  being  little 
doubt  that  the  fifth  nerve  about  the  Gasserian  ganglion 
was  affected  on  both  sides. 

This  was  one  of  the  most  obstinate  and  deplorable 
cases  of  tertiary  syphilis  I  have  ever  seen.  In  the  pre- 
iodide  days  they  appear  to  have  been  common. 

IV. — InU'a-cra7iial  guinmata  may  cause  severe 
neuralgia,  which,  as  a  rule,  is  curable  by  iodides. 

"  The  anterior  part  of  the  temporal  fossa  is  a  not 
uncommon  situation  for  a  syphilitic  gumma.  In 
this  position  it  causes  neuralgia  over  the  v^hole  of 
the  temporal  fossa,  accompanied  by  marked  tender- 
ness of  the  superficial  structures,  not  only  over  the 
actual  gumma  itself,  but  over  a  vi^ide  area  in  front 
of  it,  spreading  out  above  and  in  front  somewhat 
like  a  fan.  This  area  corresponds  to  the  distribu- 
tion of  the  ascending  branches  passing  from  the' 
deep  parts  of  the  fossa  forwards  and  upwards  to 
the  scalp.  It  does  not  correspond  to  any  area  or 
combination  of  areas  of  referred  pain.     .     .     .^'^ 

To  this  observation  of  Dr.  Head's  I  am  able  to 
add  an  explanation  of  the  neuralgia  which  certainly 
holds  good  in  some  if  not  all  the  cases,  namely,  that 
the  gumma  leads  by  extension  to  an  inflammation 
of  the  wall  of  the  cavernous  sinus  and  thus  to  a 
neuritis  of  the  fifth  nerve. 

Fig.  I  shows  two  vertical  sections  through  the 
carotid  artery   and   cavernous   sinus.      On    the    left 

^  Head,  '*  Allbutt's  System  of  Medicine,"  vol.  vi.,  p.  736. 


10 

side,  normal  for  sake  of  comparison,  the  relation  of 
the  various  nerves  and  the  Gasserian  ganglion  are 
clearly  shown.  On  the  right  side  of  the  figure  all 
traces  of  the  cavernous  sinus  have  disappeared  ;  the 
nerves  are  distorted  by  inflammation  and  pressure  ; 
the  carotid  artery  is  much  narrowed,  and  contains 
an  organised  clot,  which  does  not  block  the  lumen. 
The  wall  of  the  sinus  is  greatly  thickened  and  was 
adherent  to  the  temporo-sphenoidal  lobe  (syphilitic 
infiltration).  The  case  was  reported  by  Dr.  A.  H, 
Robinson  and  myself^  and  was,  I  believe,  the  first 
one  published  which  demonstrated  this  pathological 
nature  of  ophthalmoplegia.  Brief  notes  of  the  case 
are  as  follows  : — 

F.  S.,  a  man,  aged  53,  under  care  for  a  tertiary  ulceration 
of  one  leg.  In  September,  1885,  radiating  pain  came  on 
in  right  temple  and  occiput,  also  in  the  eye.  This  persisted 
for  seven  months,  being  somewhat  relieved  by  iodides,  and 
having  the  fan-like  distribution  alluded  to  above  by  Dr. 
Head.  There  was  also  present  with  it  complete  ophthalmo- 
plegia, which  improved  from  time  to  time  under  iodides.  In 
April,  1886,  he  contracted  cellulitis  of  his  leg  from  infection 
of  the  ulcer  and  died  of  septicaemia. 

It  will  be  seen  from  fig.  i  that  all  the  nerves  in  the  wall 
of  the  cavernous  sinus  (motor  and  sensory)  were  so  inflamed 
and  degenerated  as  to  be  almost  unrecognisable  as  such. 
The  apex  of  the  tempero-sphenoidal  lobe  was  affected  with 
gummatous  softening  and  was  adherent  to  the  thickened 
dura.  It  is  of  interest  to  note  that,  although  the  opposite 
sinus  looked  normal  to  the  naked  eye,  microscopic  exami- 
nation proved  that  the  inflammatory  process  had  spread 

^  Ophthalmological  Society's  Transactions,  1887,  vol.  vii.,  p.  250. 


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across  and  would  doubtless  have  produced  similar  paralysis 
had  iodides  not  been  given  freely. 

In  the  same  vol.  of  the  Ophth.  Soc.  Trans. ,^  I 
recorded  an  exactly  similar  case  of  ophthalmoplegia 
and  neuralgia  (fan-like  distribution  over  the  side  of 
the  head)  which  was  entirely  cured  by  iodides  and 
which  doubtless  had  the  same  pathology.  It  should 
be  noted  that  in  both  the  neuralgia  was  accompanied 
by  marked  impairment  of  sensation,  thus  resembling 
the  cases  due  to  pressure  by  a  new  growth  in  the 
region  of  the  cavernous  sinus  (see  p.  38),  It  would 
appear  that  the  pain  produced  by  tumour  pressure 
in  this  region  is  usually  more  severe  than  that  set 
up  by  syphilitic  infiltration  and  inflammation  of  the 
nerves,  though  the  difference  may  be  chiefly  due  to 
the  relief  given  by  iodides  in  the  latter  class. 

Inasmuch  as  tabes  dorsalis  generally  occurs  in 
those  who  have  had  syphilis,  it  might  almost  be  fair 
to  include  tabetic  neuralgia  in  the  above  list.  But 
that  syphilis  is  not  the  sole  cause  of  tabes  is  gene- 
rally admitted.  The  occurrence  of  spasmodic  neu- 
ralgia in  the  limbs  and  trunk  in  those  afflicted  with 
ataxia  is  very  common,  and  Dr.  Buzzard^  pointed 
out,  over  twenty  years  ago,  the  important  relation 
that  sometimes  exists  between  facial  neuralgia  and 
tabes  dorsalis.  He  showed  that  the  first  symptoms 
of  tabes  may  be  severe  shooting  pain  in  the  fifth 

^  Vol.  vii.,  p.  256. 

^  "  Clinical  Lectures  on  Diseases  of  the  Nervous  System," 
1882,  p.  143. 


12 


nerve  area ;  that  the  tabetic  neuralgia  may  be 
followed  by  anaesthesia,  and  concurred  with  Pierret^ 
in  thinking  that  sclerosis  of  the  descending  spinal 
root  of  the  fifth  nerve  was  probably  the  cause. 
The  diagnosis  is  a  matter  of  much  importance.  Dr. 
Buzzard  writes  :  "  In  an  ordinary  case  of  trigeminal 
neuralgia  it  is  most  common  to  find  the  pains  limited 
to  the  district  of  one  or  more  of  the  three  divisions 
of  the  nerve.  .  .  .  But  in  the  pains  . 
which  occur  in  the  reo"ion  of  the  fifth  nerve  in  tabes 
this  accurate  mapping  out  of  the  district  of  one  or 
other  division  of  the  nerve  is  not,  according  to  my 
experience,  observed."  Too  much  must  not,  how- 
ever, be  made  of  this  point,  as  a  reference  to  the 
case  on  p.  122  will  show.  More  important  is  the 
fact  that  true  epileptiform  neuralgia  is  always  one- 
sided ;  that  due  to  tabes  may  affect  both  sides  of  the 
head.  "  Flying,  so-called,  neuralgic  pains  in  the  head, 
when  they  attack  both  sides  and  do  not  7nap  out  the 
district  of  07ie  or  other  division  of  the  fifth  nerve, 
should  lead  to  attentive  examination  for  symptoms 
of  tabes  "  (Buzzard). 

Neuralgia  due  to  Dental  Causes. 

Almost  everyone  has  had  personal  experience  of 
the  acute  pain  caused  by  carious  teeth,  alveolar 
suppuration  and  the  like.     Although  the  cause  may 

^  "  Essai  sur  les  Symptomes  Cephaliques  de  Tabes  Dor- 
salis."     Paris,  1876. 


13 

be  limited  to  one  tooth,  the  neuralgia  is  frequently 
wide-spread,  and  may  be  paroxysmal  in  character, 
though  very  rarely  epileptiform  in  the  sense  of 
having  intervals  of  complete  relief.  Besides  the 
two  common  and  easily  recognised  causes  just 
mentioned,  there  are  others,  such  as  acid  fermenta- 
tion around  the  neck  of  a  tooth,  ulceration  of  gums 
(sometimes  due  to  mercurial  stomatitis),  caries  or 
necrosis  of  bone  set  up  by  injury  in  tooth-extrac- 
tion, or  the  crowding  out  of  the  wisdom  teeth.  A 
very  severe  neuralgia  may  be  set  up  in  the  follow- 
ing manner  :  a  hollow  tooth  is  stopped  with  a  heavy 
metal  stopping  before  the  cavity  has  been  thoroughly 
disinfected  or  the  nerve  destroyed.  In  such  cases 
weeks  or  months  of  suffering  may  ensue,  only  to  be 
relieved  by  the  removal  of  the  stopping  or  the 
extraction  of  the  tooth. 

Without  doubt,  the  worst  and  most  persisting 
cases  of  dental  neuralgia  may  simulate  tic  dou- 
loureux, and  even  lead  to  the  discussion  of  operation 
upon  the  fifth  nerve  ;  but  careful  examination  of  the 
teeth  and  gums,  and  consultation  between  dentist 
and  surgeon,  should  guard  against  either  of  two 
errors  being  committed.  The  first  is  one  too 
commonly  made,  namely,  the  useless  extraction  of 
normal  teeth  in  cases  of  true  epileptiform  neuralgia. 
The  second  is  less  apt  to  occur ;  the  performance 
of  neurectomy,  or  even  excision  of  the  Gasserian 
ganglion,  in  a  case  where  dental  extraction,  &c., 
would  suffice. 


14 

In  the  foregoing  account  of  "  minor  neuralgia  " 
the  treatment  required  has  been  indicated  by  the 
varying  causes,  but  in  a  considerable  proportion  of 
cases  no  cause  can  be  definitely  assigned.  For 
these,  empirical  measures  may  be  of  use,  the  fol- 
lowing being  a  selection  from  the  ever  growing  list 
of  such  remedies. 


I. — Internal  Treatment  by  Medicine. 

The  importance  of  iodides  (potassium,  sodium, 
and  ammonium)  in  cases  having  a  syphilitic  origin 
is  obvious.  They  may  possibly  be  of  advantage  in 
a  few  other  cases,  from  their  influence  in  lowering 
blood-pressure,  but  the  depression  they  are  apt  to 
cause  is  a  drawback  to  their  use. 

Qtiinine  has  a  great  reputation,  and  amongst  the 
preparations  of  it  may  be  mentioned  the  valerianate 
(in  5-grain  doses),  the  hydrobromide  (2  to  5  grains), 
and  the  salicylate  (5  to  10  grains).  The  hydro- 
bromide  may  be  given  hypodermically. 

Cannabis  Indica  (in  doses  of  one-fourth  to  one 
grain)  is  a  more  dangerous  drug,  and  should  be 
resorted  to  only  in  severe  and  special  cases.  In  a 
few  cases  it  .appears  to  be  the  only  remedy  which 
relieves,  though  its  toxic  effects  may  be  as  bad  as 
the  disease  for  which  it  is  given. 

The  same  objection  applies  to  Gelsemiuni  (five  to 
fifteen  minims  of  the  tincture).  Sir  Victor  Horsley 
states    that   poisonous    doses    of.  this  drug,    in  his 


15 

experience,  have  alone  relieved  true  epileptiform 
neuralgia. 

Citrate  of  caffein  is  comparatively  harmless,  but 
only  does  good  in  slight  cases  of  neuralgia  ;  aconite 
preparations  are  dangerous  and  rarely  successful  ; 
bromides  depress  and  are  of  little  use. 

Morphia  will  always  check  pain,  but  most  will 
agree  with  Prof.  Krause  in  holding  that  it  should 
be  entirely  banished  from  the  therapeutics  of  neu- 
ralgia, as  from  those  of  intestinal  obstruction.  The 
only  exceptions,  in  the  former  case,  are  those  where 
the  cause  of  the  neuralgia  can  be  recognised  and 
removed,  {e.g.,  a  carious  tooth)  but  some  temporary 
alleviation  is  required  for  the  intense  pain. 

Its  use  in  epileptiform  neuralgia  is  a  grave 
blunder,  or  worse.  Ever-increasing  doses  are 
required,^  and  the  patient  becomes  both  a  mental 
and  physical  wreck.  The  operation  which  will  alone 
cure  him  is  deferred,  and  the  patient  becomes  less 
and  less  fit  to  undergo  it. 

II. — Local  Treatment  of  the  Ne7'ves  and  Skin. 

The  inunction  of  various  sedatives  may  be  useful 
— such  as  equal  parts  of  mesotan  (a  derivative  of 
salicylic  acid)  and  olive  oil,  menthol  and  oleic  acid, 
the  unguentum  aconitinse,  etc. 

1  In  one  case  recorded  by  Prof.  Billroth,  the  patient,  before 
the  end  came,  was  taking  nearly  half-an-ounce  of  morphia 
hypodermically  every  day ! 


i6 

Freezing  the  skin  with  chloride-of-ethyl  spray  has 
been  recommended,  but  is  more  Hkely  to  do  harm 
than  good. 

Galvanism  and  electricity  in  all  forms  have  had  a 
wide  trial,  but  all  that  can  be  said  is  that  they  are 
occasionally  useful. 

The  application  of  warm  dry  heat  is  sometimes 
efficacious. 

The  hypodermic  injection  of  osmic  acid  into  the 
nerve-trunk  chiefly  concerned  is  most  uncertain  ;  it 
may  be  put  on  a  level  with  nerve-stretching  in  being 
sometimes  of  temporary  benefit.  A  2-per-cent. 
solution  is  usually  employed,  and  the  attempt  made 
to  hit  the  nerve-trunk  with  the  point  of  the  syringe- 
needle  before  the  injection  is  made.  The  writer  has 
no  personal  faith  in  the  method. 


CHAPTER  II. 

Epileptiform   Neuralgia  ;    its  Course  and 
Symptoms. 

The  disease  to  be  discussed  is  also  known  by  the 
scientific  name  of  neuralgia  quinti  major  and  by  the 
inexact  but  familiar  term  of  tic-douloureux.  As 
the  latter  is  often  used  to  include  cases  of  minor 
neuralgia  it  is  best  to  discard  it  entirely.  It  is  im- 
portant to  define  the  class  "epileptiform  neuralgia" 
as  closely  as  possible,  since  in  it  alone  are  the 
important  operations  on  the  Gasserian  ganglion 
indicated.  Whilst  examples  of  it  are  frequently 
mistaken  in  the  earliest  stage  of  the  disease,  diffi- 
culty can  rarely  arise  when  it  is  well  established. 
The  chief  features  of  true  epileptiform  neuralgia  are 
as  follows : — 

(i)  It  is  almost  invariably  unilateral. 

(2)  It  commences  in  the  distribution  of  either  the 
second  or  third  division  of  the  fifth  nerve,  and  tends 
to  involve  both  to  the  same  extent. 

(3)  The  first  (ophthalmic)  division,  so  frequently 
concerned  in  cases  of  minor  neuralgia,  is  involved 
comparatively  little  in  epileptiform  neuralgia. 
Radiations   of  pain   in  the   ophthalmic   distribution 


i8 

and    that    of   the    cervical    nerves    often,    however, 
occur. 

(4)  The  attacks  of  pain  are  paroxysmal  or 
spasmodic  and  tend  to  steadily  increase  in  severity, 
whilst  the  intervals  of  freedom  from  pain  shorten. 

(5)  During  each  attack  there  is  usually  spasm 
of  the  facial  muscles  on  the  affected  side. 

(6)  No  cause  can,  as  a  rule,  be  assigned  for  the 
onset  of  the  disease,  but  talking,  eating,  or  exposure 
of  the  skin  to  slight  cold  or  light  pressure,  invari- 
ably bring  on  the  attacks  when  the  disease  is  well 
established. 

(7)  The  subjects  of  the  disease,  at  its  onset,  are 
usually  adults  between  the  ages  of  30  and  50.  Males 
are  more  often  the  subjects  of  it  than  females. 

(8)  Its  progress  is  one  of  steadily  increasing 
severity,  lasting  an  indefinite  number  of  years. 

Spontaneous  cure  is  almost  unknown. 

(9)  Medical  treatment,  except  increasing  doses 
of  morphia,  has  little  or  no  effect.  All  kinds  of 
operations  on  the  peripheral  branches  of  the  fifth 
nerve  may  give  temporary  relief. 

(10)  Partial  or  complete  removal  of  the  Gas- 
serian  ganglion  alone  affords  a  permanent  cure. 

The  summary  given  above  will  render  unneces- 
sary a  detailed  account  of  all  the  symptoms,  which 
has  been  admirably  given  by  Dr.  Head^  and  other 
writers,  such  as  Professors  Krause  and  Trousseau. 


^  Dr.  Clifford  Allbutt's  "System  of  Medicine,"  vol.  vi.,  pp. 
28  to  233. 


1 

1 

^^^^^^^■^^ 

Sw 

****»»i^. 

T 

Fig.  2. 

From  photograph  taken  during  a  severe  and  typical  attack  of  trigeminal 
neuralgia.  The  left  fifth  nerve  was  concerned,  but  it  will  be  noticed  there 
is  convulsive  spasm  of  the  facial  muscles  on  the  right  side  as  well  as  of  the 
depressors  of  the  lower  jaw.  The  temporal  artery  becomes  prominent 
during  an  attack.  The  expression  of  agony  is  fairly  well  conveyed  in  the 
reproduction. 


19 

One  of  its  most  striking  features  is  the  strictly 
unilateral  nature  of  the  complaint ;  two  exceptions 
only  to  this  rule  are  mentioned  by  Krause  and 
Head,  in  the  latter  case  the  neuralgia  had  lasted 
twenty-five  years.  However  long  the  duration 
of  neuralgia,  there  is  no  disturbance  of  sensation 
except  when  produced  by  neurectomy  or  other 
operation.  The  question  of  trophic  disturbance  in 
the  area  of  skin  and  mucous  membrane  will  be  dis- 
cussed later  (see  page  26). 

During  the  intervals,  which  at  first  may  be  of 
weeks'  or  months'  duration,  the  patient  is  entirely 
free  from  pain  ;  in  this  respect  a  marked  contrast 
exists  to  most  cases  of  minor  neuralgia.  In  ad- 
vanced cases,  however,  the  attacks  occur  with  only 
a  few  minutes'  interval.  Touching  the  skin  lightly 
with  a  handkerchief  or  feather  at  first  may  produce 
an  attack  ;  later,  the  act  of  mastication  or  the  attempt 
to  talk  will  bring  it  on.  Night  and  day  the  parox- 
ysms occur  ;  so  that,  from  loss  of  sleep  and  impaired 
nutrition,  the  patient's  condition  becomes  an  utterly 
miserable  one.  Billroth  graphically  pictures  such 
a  case :  "I  can  see  him  now  before  me,  emaciated 
to  a  skeleton,  with  a  rigid,  staring  expression,  with 
the  saliva  dribbling  from  his  open  mouth,  with 
white,  neglected  beard  and  long,  unkempt  hair."  It 
is  no  wonder  that  such  sufiferers  seek  relief  in 
suicide,  or,  what  is  almost  as  bad — the  morphia 
habit. 

Fig.  3  illustrates  the  state  of  mental  degradation 


20 


which  was  induced  in  one  of  my  cases  by  his  pro- 
longed suffering  and  abuse  of  morphia.  The  upper 
specimen  of  hand- writing  was  written  by  the  patient 
(a  man  of  about  50),  in  answer  to  the  strong  appeal 
to  undergo  the  radical  operation.      It  was  the  best 


.(h,..c<4^j..^^ .       ^^     /itn^   J^. 


^a^y^*^ . 


Fig. 


attempt  at  writing  he  could  do,  and  the  contrast 
with  his  natural  hand  a  year  after  the  operation  is 
most  striking. 

Cases  of  suicide  directly  due  to  epileptiform 
neuralgia  are  by  no  means  rare,  and  are  charitably 
referred  to  temporary  insanity.     We  may,  however, 


21 


fairly  ascribe  this  nervous  instability  and  loss  of 
mental  control  to  the  agony  so  long  endured,  the 
want  of  sleep  and  rest,  and  to  the  grave  effects  of 
drug-treatment.  Perhaps  the  depressing  effect  of 
many  futile  operations  must  also  be  taken  into 
account.  Thus  it  will  be  seen  there  is  no  reason 
to  suppose  that  a  tendency  to  insanity  or  perverted 
mental  action  can  indirectly  cause  the  neuralgia ;  it 
is  far  more  probable  that  the  reverse  takes  place. 
Epileptiform  neuralgia  is  confined  to  no  class,  age, 
or  rank  in  life.  Some  of  its  sufferers  are  men  and 
women  of  the  highest  intellect,  of  the  strictest  lives  ; 
others  have  never  worked  hard  except  with  their 
hands,  and  many  have  lived  freely  as  regards 
alcohol  and  the  like.  The  disease  would  appear 
to  be  especially  prevalent  in  the  United  States,  but 
almost  every  European  country  seems  to  furnish 
its  quota  of  sufferers.  It  would  be,  however,  a 
matter  of  great  interest  to  ascertain  its  relative 
prevalence  in  India  and  other  tropical  countries  ; 
it  may  be  found  that  it  is  mainly  confined  to  those 
having  a  temperate  or  cold  season. 

The  local  distribution  of  the  neuralgia  in  epilepti- 
form cases  is  of  much  importance  as  an  indication  of 
the  form  the  operation  should  take.  Analysing  six- 
teen cases  operated  on  by  Italian  surgeons,  we  find 
that  all  three  divisions  of  the  fifth  nerve  were  in- 
volved in  only  four  (25  per  cent.).  In  the  other 
twelve  cases  the  second  division  (superior  maxil- 
lary) was   alone  concerned  in  two  cases,   the  third 


22 


in  one,  whilst  in  the  remaining  nine  (60  per  cent, 
of  the  whole  number)  the  neuralgia  affected  both 
the  second  and  third  divisions.  It  is,  therefore, 
obvious  that  in  75  per  cent,  the  surgeon  had  no 
reason  for  attempting  division  of  the  ophthalmic 
trunk,  as  removal  of  the  lower  part  of  the  ganglion 
would  suffice  for  a  cure.  Professor  Billroth,  who 
had  much  experience  in  the  treatment  of  facial 
neuralgia,  noted  that  the  nerve  affected  in  the 
majority  of  cases  is  the  superior  maxillary  division. 
Sir  Victor  Horsley  observed  the  same  fact,  and 
states  that  in  every  case  in  which  a  dental  origin 
could  be  assigned  for  typical  trigeminal  neuralgia 
the  upper  jaw  was  the  one  concerned. 

It  should,  however,  be  clearly  stated  that  true 
epileptiform  neuralgia  rarely  has  such  an  origin, 
though  it  is  hardly  necessary  to  recommend  that 
the  condition  of  the  teeth  and  gums  should  be  seen 
to  in  any  case  of  facial  neuralgia.  All  carious 
teeth  should  be  carefully  stopped,  or,  if  that  is  found 
impossible,  they  should  be  extracted.  Sometimes 
a  heavy  metal  stopping  is  the  cause  of  intense 
neuralgia,  and  septic  changes  are  only  too  apt  to 
occur  under  an  elaborate  crown  or  bridge  of  gold, 
and  to  cause  this  symptom.  But,  as  a  rule,  too 
much  attention  is  paid  by  the  physician  to  the 
teeth  in  cases  of  epileptiform  neuralgia.  Nothing 
is  more  certain  than  that  it  may  arise  in  patients 
with  no  trace  of  dental  caries  or  irritation,  and  that 
the    extraction    of   healthy  teeth    is    a  useless    and 


23 

barbarous  method  of  treatment.  In  every  case  in 
which  I  have  operated  on  the  Gasserian  gangHon  a 
number  of  such  teeth  had  been  previously  removed 
without  the  shghtest  benefit.  Such  a  measure  can- 
not be  too  strongly  condemned. 

Spasm  of  the  facial  muscles  is  rarely  absent,  at 
any  rate  during  the  severe  attacks  ;  it  is  illustrated 
by  fig.  2  taken  from  one  of  my  cases. 

Dr.  Head  notes  that  in  addition  to  the  reflex 
spasm  of  the  facial  muscles  there  may  be  fibrillary 
tremor.  The  liability  of  the  patient  to  the  attacks, 
when  once  started,  continues  as  a  rule  during  the 
remainder  of  his  life,  unless  a  curative  operation  is 
performed.  Billroth  observed  one  case  of  spontane- 
ous subsidence,  but  it  is  almost  a  solitary  exception 
to  the  rule.  It  hardly  ever  commences  before 
the  age  of  30  or  35,  often  later.  In  both  these 
respects  a  striking  contrast  is  afforded  to  migraine 
and  true  epilepsy  (which  are  also  paroxysmal  diseases 
of  the  nervous  system)  ;  both  as  a  rule  develop  in 
early  life  and  tend  to  gradual  diminution  or  dis- 
appearance after  the  age  of  50.  By  some  observers 
migraine  is  held  to  be  a  form  of  neuralgia  which  is 
practically  confined  to  the  ophthalmic  division  of  the 
fifth  nerve,  and  possibly  started  by  exposure  of  the 
supra-orbital  regions  to  cold.^  In  its  distribution, 
the  age  of  its  onset,  and  its  tendency  to  cure,  it 
differs  completely  from  epileptiform  neuralgia. 

^  Anstie,  Sinkler,  &c. 


24 

Has  epileptiform  neuralgia  any  relation  to  true 
epilepsy  ?  —  Trousseau  discusses  this  point  and 
mentions  two  cases  in  which  the  diseases  co-existed, 
but  this  does  not  take  one  far.  He  was  evidently 
unwilling  to  admit  their  close  relation,  and  rightly 
so  ;  but  he  wrote  that,  if  it  proved  that  the  family 
histories  of  the  subjects  of  epileptiform  neuralgia 
revealed  **  neuroses,"  he  would  have  to  bracket  the 
two.  The  evidence  hitherto  collected  shows  that 
the  sufferers  from  true  epileptiform  neuralgia  can 
neither  blame  their  immediate  ancestors  for  nervous 
bequests,  nor  themselves  with  contributing  self- 
indulgence  in  their  habits  of  life.  Epileptiform 
neuralgia  has  no  apparent  relation  to  the  use  of 
alcohol  or  tobacco,  to  syphilis,  to  gout,  perhaps  not 
even  to  that  vague  entity,  "the  rheumatic  tendency." 

Sir  V.  Horsley,  in  enumerating  the  possible  causes, 
attaches  most  importance  to  three — alcoholic  excess, 
traumatism,  and  dental  or  peridental  inflammation. 
The  opinion  of  such  an  authority  deserves  the 
highest  respect,  but  cases  of  true  facial  neuralgia  of 
unsurpassed  intensity  are  met  with  in  those  who 
(i)  have  been  teetotalers  all  their  lives,  (2)  have 
sustained  no  injury  whatever  to  the  head,  and 
(3)  have  never  known  the  pangs  of  toothache. 

The  late  Dr.  Anstie  made  the  interesting  sug- 
gestion that  in  the  subjects  of  epileptiform  neuralgia 
there  was  apt  to  be  associated  the  taint  of  insanity. 
In  many  of  the  recorded  cases  the  patients  before 
operation  are  described  as  being  strange  in  their 


25 

manner,  perhaps  threatening  suicide,  or  actually 
delirious,  whilst  delirium  has  sometimes  come  on 
immediately  after  the  operation  ;  but  these  symptoms 
of  mental  derangement  are  probably  due  to  pro- 
longed suffering  and  loss  of  sleep.  There  is  really 
no  evidence  of  the  connection  between  epilepti- 
form neuralgia  and  any  neurosis  ;  the  disease  stands 
by  itself.  In  the  next  chapter  will  be  discussed 
the  question  of  its  pathology. 


CHAPTER    III. 

The    Nature    and    Pathology   of    Epileptiform 
Neuralgia. 

It  is  improbable  that  the  typical  epileptiform 
neuralgia,  for  which  operations  on  the  Gasserian 
ganglion  are  so  successful,  depends  upon  a  true 
neuritis.  The  intervals  of  complete  freedom  from 
pain,  which  early  in  the  case  may  be  of  many  weeks' 
duration,  and  the  fact  that  neither  motor  paralysis 
nor  cutaneous  anaesthesia  ever  attends  the  neur- 
algia however  inveterate,  place  the  affection  in  an 
entirely  different  category  from  the  well-known 
peripheral  neuritis  of  the  limbs.  It  is  true  ,that 
some  symptoms  which  might  be  termed  trophic 
(such  as  oedema,  persistent  congestion,  or  dermatitis) 
are  occasionally  met  with  in  the  regional  distribution 
of  the  intense  epileptiform  neuralgia,  but  traumatic 
irritation  by  the  patient  in  the  hope  of  obtaining 
some  relief  is  the  usual  cause  of  such  symptoms. 
In  several  of  my  cases  the  patient  during  each 
spasm  of  pain  used  to  violently  grasp  at  the  skin 
involved  as  though  to  tear  it  away,  and  no  wonder 
such  a  habit  led  to  some  "  trophic  "  effects, 

W.  W.  Keen  states  that  he  has  seen  two  cases  of 
corneal  ulceration  and  opacity  in  conjunction  with 


27 

trigeminal  neuralgia,  but  on  reference  to  his  notes  of 
these  cases  one  finds  no  record  whatever  of  eye- 
trouble  in  one  of  them ;  in  the  other,  the  eye  concerned 
had  been  the  subject  of  chronic  glaucoma,  and  the 
lens  had  already  been  removed  !  I  know  of  no  other 
instances  in  which  the  neuralgia  was  associated  with 
trophic  changes  in  the  eye,  and  obviously  Keen's 
cases  prove  nothing.  It  is  of  course  well  known 
that  herpes  frontalis  and  nasalis  may  be  attended 
with  conjunctivitis  and  corneal  ulcers,  sometimes 
even  with  sloughing  of  the  eye.  In  herpes  the 
existence  of  a  neuritis  involving  the  Gasserian 
ganglion  has  been  proved,  and  the  fact  that  eye 
changes  never  occur  in  paroxysmal  neuralgia  of 
the  fifth  nerve  is  a  strong  argument  against  the 
latter  being  due  to  neuritis. 

It  is  true  that  Spiller,  who  examined  the- 
nerves  and  ganglia  in  several  cases,  described- 
globular  degeneration  of  the  myelin-sheaths,  but 
this  is  no  proof  of  inflammation,  and  moreover,  he 
admits  that  the  same  changes  may  be  found  in 
other  nerves  which  are  not  the  seat  of  neuralgia. 
Spiller  also  described  thickening  of  the  arterial  walls 
in  the  Gasserian  ganglion,  swelling  of  the  axis- 
cylinders,  &c.  Keen  considers  that  true  pathological 
changes  were  proved  in  six  out  of  seven  cases  ex- 
amined by  Spiller,  but,  as  in  excision  of  the  ganglion 
it  is  impossible  to  avoid  a  somewhat  rough  handling 
of  the  delicate  nerve-structures,  this  statement  must 
be  accepted   with  great  reserve.     Peculiar  staining 


28 

methods  are  also  responsible  for  some  of  the 
changes  which  have  been  found.  This  does  not,  of 
course,  apply  to  diseases  of  the  blood-vessels  in 
the  ganglion  (such  as  extreme  narrowing  of  their 
lumen).  It  is  doubtless  true  that  arterio-sclerosis 
has  been  occasionally  found,  but  that  it  is  often 
present  in  connection  with  epileptiform  neuralgia 
is  certainly  not  the  case.  How,  then,  can  it  be  the 
cause  of  such  neuralgia  if  it  only  exists  in  a  small 
minority  of  the  cases  ?  Again,  typical  epileptiform 
neuralgia  is  met  with  at  an  age  when  arterial 
sclerosis  hardly  occurs  ;  in  thirteen  cases  out  of 
thirty-two  it  commenced  between  30  and  40  years 
—Billroth. 

I  believe  the  theory  of  vascular  degeneration  as 
the  chief  cause,  or  even  as  a  cause,  of  trigeminal 
neuralgia  should  be  entirely  rejected.  It  is  more 
difficult  to  disprove  the  theory  of  spreading  neuritis, 
which  has  the  strong  support  of  Sir  Victor  Horsley,^ 
who  regards  *'  true  neuralgia  "  as  being  synonymous 
with  neuritis,  and  suggests  that  the  inflammation 
often  commences  in  the  small  dental  nerves,  and 
spreads  up  along  the  larger  branches  to  the  Gasserian 
ganglion. 

Horsley,  however,  admits  that  the  only  changes 
in  the  peripheral  branches  he  has  ever  found,  con- 
sist in  thickening  of  their  fibrous-tissue  sheaths  ; 
that  the  nerve-tubules  are  normal,  and  further,  that 
the  Gasserian  ganglion  shows  no  changes  except  a 
varying  degree  of  adhesion  to  its  dural  investment. 

^  Horsley,  Clinical  Journal,  1897,  '^'o^-  ^i->  PP-  ^  and  17. 


Fig.  4. 

Section  of  Gasserian  ganglion  removed  from   case  of  inveterate    trigeminal 
neuralgia.     The  ganglion  cells  are  seen  to  be  perfectly  normal. 


29 

Spiller  and  Keen,  on  the  other  hand,  attach  import- 
ance to  degeneration  of  the  myehn-sheaths  of  the 
nerves,  whilst  Billroth  states  that  microscopical 
examination  of  the  excised  peripheral  nerves  proved 
in  so  many  cases  absolutely  negative  that  it  was 
given  up  as  useless. 

Schwab  examined  two  Gasserian  orangflia  which 
had  been  extirpated,  the  operation  following  others 
which  had  been  performed  on  the  peripheral 
branches  of  the  fifth  nerve.  He  found  slight 
changes  in  both  ganglia,  but  in  neither  case  did  he 
reoard  them  as  sufficient  to  account  for  the  neuralg^ia. 
However,  he  attributed  the  neuralgia  to  one  of 
three  causes,  a  peripheral  neuritis,  an  interstitial 
inflammation  of  the  ganglion  itself,  and  a  neuritis  of 
the  sensory  root  of  the  ganglion,  of  which,  he  says, 
there  are  two  instances  recorded.  It  is  very, 
doubtful  whether  any  such  changes  are  really  pre- 
sent. Amongst  those  who  have  recorded  entirely 
negative  results  from  thorough  examination  of 
the  removed  ganglia  may  be  mentioned  Monari,* 
Codivilla  (three  cases),  myself  (specimens  examined 
by  Dr.  Henry  Head,  F.R.S.),  and  Dr.  J.  Crawford 
Renton.  Prof.  Krause's  observations  on  both 
peripheral  nerves  and  ganglia,  resected  for  trige- 
minal neuralgia,  have  also  been  negative,  and  he 
suggests  that  "perhaps  the  changes  escape  our 
detection  because  they  are  molecular." 

Fig.  4  represents  a  section  through  the  ganglion 

'  Monari,  Beitrdge  ziir  Klinische  Chirnrgie,  Band  xvii.,  1896. 


30 

from  one  of  my  cases.  It  shows  well  the  ganglion- 
cells  and  supporting  connective  tissue.  It  will  be 
seen  that  the  ganglionic  cells  are  in  no  way  com- 
pressed ;  the  fact  that  they  differ  much  in  size  is 
due  to  the  section  cutting  through  some  at  their 
centres,  and  others  at  the  periphery.  The  minute 
cells  of  the  neuroglia  are  not  more  numerous  than 
is  normal,  and  nowhere  is  there  the  slightest 
evidence  of  inflammation.  In  fact,  the  section 
might  be  taken  to  illustrate  the  normal  structure 
of  such  a  ganglion. 

Fig.  5  is  taken  from  a  section  through  one  of 
the  main  branches  of  the  fifth  nerve  just  beyond 
the  ganglion,  also  from  a  case  of  inveterate 
trigeminal  neuralgia.  The  dense  fibrous  sheath  is 
perfectly  normal,  as  are  also  the  nerve-tubules. 
Attention  is  drawn  to  a  small  artery  cut  across  in 
the  nerve  ;  its  wall  is  in  no  way  altered  from  the 
normal. 

It  may  therefore  be  taken  as  proved  that  in  many 
cases  of  epileptiform  neuralgia  of  long  duration  the 
Gasserian  ganglion  and  its  main  branches  show  no 
pathological  change,  and  that  the  disease  has, 
moreover,  no  relation  to  impaired  blood-supply 
due  to  arterial  narrowing,  &:c.  The  few  observers 
who  have  described  abnormal  appearances  in  micro- 
scopic sections  from  such  cases  vary  much  in  their 
accounts. 

These  facts  lead  one  to  the  conclusion  stated 
on  p.  I,  that  the  pathology  of  epileptiform  neuralgia 
is  still  unknown. 


Fic.   5. 

Section  through  a  main  branch  of  the  fifth  nerve,  from  a  case  of 
epileptiform  neuralgia. 


31 

We  will  now  consider,  as  throwing-  some  lioht 
upon  the  subject,  the  question  of  tumours  involving 
the  Gasserian  ganglion. 

Cases  illustrating  this,  though  very  uncommon, 
are  yet  of  special  interest ;  they  afford  the  clearest 
evidence  of  a  central  origin  for  neuralgia  of  the 
fifth  nerve,  and  in  some  instances  the  pain  closely 
resembles  that  of  "  idiopathic "  epileptiform  neu- 
ralgia. Almost  always,  however,  there  is  evidence 
of  pressure  on  the  neighbouring  nerves,  the  carotid 
artery,  or  the  cavernous  sinus,  with  marked  anaes- 
thesia, and  the  diagnosis  of  tumour  can  usually  be 
made  before  the  operation.  The  following  is  a 
brief  account  of  the  chief  recorded  cases  of  the 
kind  : — 

A  man,  aged  50,  was  sent  to  me  by  Dr.  Henry 
Head,  with  partial  oculo-motor  paralysis  on  one 
side,  severe  neuralgia  of  the  corresponding  fifth 
nerve,  and  partial  anaesthesia.  An  exploratory 
operation  by  the  temporal  route  showed  an  exten- 
sive ossifying  chondroma  or  chondro-sarcoma 
growing  from  the  apex  of  the  petrous  bone  and 
invading  the  Gasserian  ganglion.  Partial  removal 
of  the  growth  was  alone  possible,  the  patient  re- 
covering from  the  operation. 

Kosinski,^  in  a  case  like  the  preceding  one, 
attempted  a  complete  removal  of  the  tumour,  but 


^  Kosinski   in    Chipault's    "  Chirurgie   Nerveuse,"   vol.    ii. 
P-  195- 


32 

with  fatal  result.  His  patient  was  a  woman,  aged 
53,  whose  right  eye  was  atrophied,  and  in  whom 
the  right  facial  and  trigeminal  nerves  were  paralysed, 
A  tumour  could  be  felt  in  the  right  nasal  cavity. 
The  upper  jaw  on  that  side  was  resected,  and  a 
tumour  growing  from  the  base  of  the  skull  was 
removed ;  it  penetrated  into  the  cranial  cavity.  At 
the  autopsy  the  tumour  was  found  to  have  been  only 
partially  removed  ;  it  was  an  osteo-sarcoma  and  was 
said  to  have  started  from  the  Gasserian  ganglion 
itself.  This,  however,  must  have  been  a  mistake  ; 
it  was  connected  with  the  sella  turcica,  the  sphe- 
noidal sinus,  and  the  bone  forming  the  anterior 
lacerated  foramen.  It  is  obvious  that  it  was 
impossible  to  remove  such  a  growth,  and  it  is 
inconceivable  that  an  osteo-sarcoma  should  start 
in  the  Gasserian  ganglion  itself. 

This  was,  however,  the  origin  of  a  tumour 
described  by  R.  W.  Smith  as  a  neuroma,  but  which 
should  rather  be  termed  a  true  sarcoma.  The  case 
was  of  such  interest  that  the  drawing  and  descrip- 
tion are  here  reproduced  ^  (see  fig.  6). 

"  In  this  instance  the  tumour  implicated  the  Gas- 
serian ganglion,  and  was  the  source  of  more  severe 
and  uninterrupted  suffering  than  I  have  ever  wit- 
nessed either  in  this  or  any  other  affection. 

^  R.  W.  Smith's  "  Monograph  on  Neuroma  "  was  published 
in  1849,  and  reproduced  in  1898  by  the  New  Sydenham 
Society.  This  case  was  probably  one  of  the  first  recorded 
of  tumour  of  the  Gasserian  ganglion. 


Fig.  6. 


Tumour  involving  Gasserian  ganglion  (R.  W.  Smith's  case).  The  growth 
T  is  seen  to  be  mainly  within  the  dura  mater,  but  a  prolongation  extends 
through  the  foramen  ovale  along  the  inferior  maxillary  nerves  (I.M.). 
O.D.   The  ophthalmic  division. 


33 

"  In  the  year  1836  an  emaciated  and  unhealthy- 
looking  female,  about  40  years  of  age,  was  admitted 
into  the  Richmond  Hospital,  under  the  care  of  Dr. 
Hutton,  complaining  of  neuralgia  of  the  right  side 
of  the  face.  She  stated  that  the  pain  had  com- 
menced several  months  previously,  had  gradually 
increased  in  severity,  and  had  now  become  almost 
unsupportable  ;  she  had  lost  flesh,  her  sleep  was 
broken,  and  her  appetite  had  failed.  Her  counte- 
nance indicated  extreme  suffering ;  the  pain  (which, 
although  subject  to  exacerbations,  never  altogether 
ceased)  was  accurately  limited  to  the  right  side  of 
the  face  and  forehead,  and  when  indicating  the 
situations  in  which  it  was  most  severe  the  patient 
marked  with  her  finger  the  course  of  the  branches 
of  the  fifth  pair  of  nerves,  and  more  especially  the 
point  of  exit  of  the  superior  maxillary  from  the 
infra-orbital  foramen.  Her  sufferings  were  so 
much  increased  by  mastication  that  she  ate  but 
little,  and  speaking  aggravated  the  pain  to  such  a 
degree  that  she  always  remained  silent  unless  when 
interrogated,  and  even  upon  these  occasions  she 
frequently  replied  by  signs.  She  had  no  respite 
from  suffering  during  the  day,  and  at  night  sleep 
seldom  came  to  her  relief,  nor  did  any  of  the 
numerous  remedies  employed  succeed  in  affording 
even  temporary  ease.  After  having  endured  more 
severe  and  more  uninterrupted  pain  than  I  have 
ever  witnessed  in  any  other  instance,  death  termi- 
nated her  protracted  agonies,  four  months  subse- 
quent to  her  admission  into  the  hospital. 


34 

"■Autopsy. — When  the  cranium  was  opened  and 
the  brain  removed,  a  tumour  was  seen  in  the  right 
division  of  the  spheno-temporal  fossa ;  it  was  some- 
what of  the  form  and  size  of  a  walnut,  and  occupied 
the  situation  of  the  Gasserian  gangHon ;  it  extended 
across  the  inner  extremity  of  the  great  wing  of  the 
sphenoid  bone,  as  far  forwards  as  the  foramen 
lacerum  orbitale,  and  was  covered  by  the  super- 
ficial lamina  of  the  dura  mater,  which  was  attenuated 
to  a  remarkable  degree.  The  trunk  of  the  fifth 
nerve  appeared  to  enter  the  posterior  part  of  the 
tumour,  the  interior  of  which,  however,  presented 
no  trace  of  nervous  structure ;  the  ophthalmic 
division  crossed  the  anterior  part  of  its  superior 
surface  ;  the  superior  maxillary  emerged  from  it  at 
the  foramen  rotundum  ;  and  the  third  division 
seemed  to  be  identified  with  a  remarkable  prolonga- 
tion of  the  tumour,  which  passed  through  the 
foramen  ovale,  the  circumference  of  which  was 
increased  to  more  than  double  its  natural  extent. 

"  The  surface  of  the  petrous  portion  of  the  tem- 
poral bone,  which  supported  the  posterior  part  of 
the  tumour,  was  absorbed,  as  well  as  the  superior 
wall  of  the  horizontal  portion  of  the  carotid  canal  ; 
between  this  rough  and  denuded  portion  of  the 
bone  and  the  deep  surface  of  the  tumour  ran  the 
Vidian  nerve,  which  throughout  its  whole  course, 
from  Meckel's  ganglion  to  the  hiatus  Fallopii,  was 
much  larger  than  natural.  The  tumour  was  solid, 
and  of  uniform   consistence  ;    its    section   exhibited 


35 

a  cellular  structure,  without  any  trace  whatever  of 
nervous  tissue  ;  nerve-fibres  could,  however,  by  the 
assistance  of  the  microscope,  be  seen  upon  various 
parts  of  its  surface.  The  non-ganglionic  portion  of 
the  nerve  was  compressed,  but  not  enlarged." 

It  is  obvious  that,  whilst  this  case  was  recorded 
by  Dr.  Smith  as  being  an  example  of  neuroma, 
modern  pathologists  would  consider  it  as  a  sarcoma. 

Caponotto,  in  a  case  of  neuralgia  for  which  he 
excised  the  Gasserian  ganglion,  found  at  the  autopsy 
a  "cholesteatoma"  the  size  of  a  nut,  growing  from 
the  pons  varolii,  at  the  point  of  exit  of  the  roots 
of  the  fifth  nerve.  Lampiasi  ^  operated  by  the 
temporal  route  on  a  case  of  neuralgia  of  the  second 
division  of  the  fifth  nerve,  and  found  a  small 
sarcoma  growing  from  the  dura  mater,  which 
adhered  to  the  bone  and  pressed  on  the  nerve. 
He  was  able  to  remove  the  tumour,  and  improve- 
ment resulted,  both  as  regards  the  neuralgia  and 
the  oculo-motor  paralysis  on  the  same  side,  which 
had  been  present  for  a  short  time  before  the  opera- 
tion. It  is,  however,  most  unlikely  that  a  cure  was 
obtained. 

A  detailed  account  is  given  ^  of  a  case  of  endothe- 
lioma (or  plexiform  sarcoma)  with  a  remarkable 
clinical  history.     The  patient,  a  man  of  32,  suffered 


^  Lampiasi,  Twelfth  Congress  of  Italian  Surgeons,  1897. 
^  Dercum,    Keen   and    Spiller,   in    Chipault's    "  Chirurgie 
Nerveuse,"  vol.  iii.,  p.  714. 


36 

for  a  year  with  severe  pain  in  the  lower  limbs, 
violent  neuralgia  in  the  left  fifth  nerve,  and  in- 
creasing weakness  and  somnolence.  A  glandular 
tumour  developed  rapidly  in  the  left  side  of  the 
neck ;  on  removal,  it  was  pronounced  to  be  an 
endothelioma.  The  facial  neuralgia  increased  in 
intensity,  but  differed  from  the  ordinary  type  in 
not  being  paroxysmal  and  in  being  accompanied  by 
diminished  sensation  ;  all  three  branches  of  the  fifth 
were  moreover  equally  concerned.  In  November, 
1899,  Prof.  Keen  performed  the  Hartley-Krause 
operation  and  removed  piecemeal  a  considerable 
tumour  occupying  the  position  of  the  Gasserian 
ganglion.  The  ganglion  itself  could  not  be  made 
out,  and  the  pain  persisted  as  before.  In  a  second 
operation  a  month  later  more  of  the  tumour,  which 
destroyed  the  upper  edge  of  the  petrous  bone,  was 
removed.  The  dura  mater  was  opened  in  both 
operations  and  small  granulations  of  the  tumour 
were  seen  growing  on  it.  The  patient  recovered 
from  the  operation,  and  this  is  doubtless  all  that 
can  be  said  with  regard  to  a  cure.  It  is  of  interest 
to  note  that  he  had  for  long  suffered  from  chronic 
median  otitis,  and  it  might  be  suggested  that  the 
primary  growth  was  a  cholesteatoma  of  the  petrous 
bone.  The  glandular  tumour  in  the  neck  was 
certainly  secondary  to  the  growth  in  the  middle 
fossa  of  the  skull. 

Hagelstan    records    the    autopsy   of    a    case    of 
endothelioma    which    infiltrated  the  left    Gasserian 


37 

ganglion  ;  Trenel,  a  case  of  "  angiolithic  sarcoma," 
which  also  was  not  operated  on. 

Homen  and  Krause  observed  two  cases  of  pres- 
sure-atrophy of  the  ganglion,  due  to  endothelioma 
and  cholesteatoma  respectively.  Krause's  patient 
died  of  meningitis  two  weeks  after  operation,  owing 
to  leaking  of  cerebro-spinal  fluid  through  the  wound. 
There  is  no  object  in  separating  the  small  series 
of  cases  into  those  where  the  Gasserian  ganglion  is 
pressed  upon  and  those  in  which  it  is  infiltrated  or 
destroyed  by  the  tumour,  for  the  distinction  has  no 
practical  importance.  The  tumour  may  arise  in 
connection  with  the  apex  of  the  petrous  bone,  the 
pituitary  fossa,  the  wall  of  the  cavernous  sinus,  the 
dura  mater  elsewhere  in  this  region,  and  possibly 
even  from  the  tempero-sphenoidal  lobe. 

The  cases  given  above  may  be  classified  accord- 
ing to  their  nature  as  follows  : — 

(i)  Sarcoma  or  fibro-sarcoma  of  the  ganglion 
itself — R.  W.  Smith's  case. 

(2)  Sarcoma  of  dura  mater,  including  endothe- 
lioma, invading  the  ganglion — Hagelstan's,  Keen's, 
Trenel's,  Homen's  and  Lampiasi's  cases — five  in 
all. 

(3)  Ossifying  chondroma,  or  chondro-sarcoma 
growing  from  the  petrous  bone — J.  .Hutchinson, 
jun.,   and  Kosinski. 

(4)  Cholesteatoma — Krause  and  Caponotto. 

It  will  have  been  noticed  in  these  cases  of  tumour 
pressure  on  the  ganglion  that  besides  the  neuralgia 


produced  there  is  always  some  degree  of  anaesthesia ; 
further,  the  oculo-motor  nerves  are  sooner  or  later 
involved,  and  there  is  frequently  obstruction  of  the 
orbital  circulation  giving  rise  to  proptosis,  &c.  In 
these  respects  there  is  a  striking  contrast  to  true 
epileptiform  neuralgia. 

It  may  be  noted,  in  conclusion,  that  in  some  cases 
in  which  pathological  changes  have  been  described 
in  the  ganglion,  severe  and  repeated  operations  have 
been  performed  previously  on  its  main  extra-cranial 
branches.  It  is  conceivable  that  such  operations 
may  have  led  to  ascending  neuritis. 


CHAPTER    IV. 

The  Treatment  of  Epileptiform  Neuralgia. 

But  little  can  be  said  regarding  the  medicinal  treat- 
ment. In  former  times  free  purgation  was  held 
to  be  useful.  Belladonna  had  also  a  certain  repu- 
tation, but  Trousseau,  after  many  trials,  pronounced 
it  useless.  All  forms  of  electricity  have  been  tried, 
and  of  course  lately  the  X-rays  have  been  resorted 
to.  Of  the  host  of  hypnotics  and  sedatives,  new 
and  old,  it  can  be  said  that  temporary  relief  may 
follow  the  use  of  any  one  of  them,  but  that  only, 
disappointment  results  from  their  prolonged  admin- 
istration. Sir  Victor  Horsley  states  that  he  has 
only  seen  marked  benefit  from  tincture  of  gelse- 
mium  pushed  to  poisonous  doses.  Opium  and 
morphia  alone  will  dull  the  pain,  or  even  for  a 
time  remove  it,  but  at  what  a  cost !  In  some  of 
Trousseau's  patients  it  was  pushed  up  to  drachm 
doses  of  sulphate  of  morphia,  or  half  an  ounce  of 
opium  each  day.  In  some  patients  such  pro- 
digious doses  cause  no  marked  bad  effects,  not 
even  drowsiness ;  but  with  many  it  is  far  other- 
wise: the  mental  and  physical  condition  both  suffer; 
there  may  be  induced  constant   torpor    with  head- 


40 

ache  ;    the    digestion    fails,    and    the    patient    may- 
emaciate  to  a  marked  degree. 

Terrible  as  is  the  suffering  caused  by  epilepti- 
form neuralgia,  relief  obtained  by  increasing  doses 
of  morphia  is  only  too  dearly  bought.  When 
once  epileptiform  neuralgia  is  well  established  the 
right  treatment  consists  in  operation,  and  we  have 
now  to  consider  the  exact  form  that  this  should 
take.  Before  doing  so,  however,  a  word  of  warn- 
ing is  necessary  with  regard  to  hysterical  or 
"neurotic"  patients.  Strange  as  it  may  seem,  it 
occasionally  happens  that  epileptiform  neuralgia  is 
simulated  fairly  closely,  though  careful  examination 
should  save  patient  and  surgeon  from  the  mistake 
of  resorting  to  operation  in  such  cases.  Opera- 
tions for  hysterical  conditions  are  never  advisable. 
Even  simple  incisions,  made  with  a  view  of 
impressing  the  patient  with  a  kind  of  hypnotic 
suggestion,  only  bring  discredit  on  the  surgeon  in 
the  long  run.  How,  then,  can  a  serious  operation 
like  excision  of  the  Gasserian  ganglion  be  justified 
in  a  case  of  neuralgia  having  an  hysterical  basis  ? 
That  such  cases  may  simulate  true  epileptiform  neu- 
ralgia closely  is  undoubted.  A  good  example  of  this 
was  the  case  of  a  woman  sent  to  me  by  Dr.  R.  C.  B. 
Wall.  She  was  a  pallid  and  ill-nourished  Jewess, 
aged  44,  who  had  borne  eleven  children.  For  the 
last  three  years  she  had  had  attacks  of  neuralgia 
in  the  right  side  of  the  head  and  face,  strictly 
limited,  according  to  her  statement,  by  the  median 


41 

line.  These  attacks  came  on  shortly  before  each 
menstrual  period,  recurred  during  the  succeeding 
two  or  three  weeks,  and  left  her  with  a  free 
interval  only  of  a  week  or  so ;  but  the  attacks 
were  not  increasing  in  intensity,  nor  were  they  of 
the  explosive  character  of  epileptiform  neuralgia : 
on  the  other  hand,  the  pain  would  last  for  some 
days  continuously,  and  sometimes  numbness  or 
pain  of  one  side  of  the  body  would  accompany  it. 
The  case  was  evidently  one  in  which,  in  an 
anaemic  woman,  neurasthenia,  due  to  poor  living 
and  repeated  pregnancies,  was  to  blame,  and  one 
in  which  operation  was  quite  out  of  the  question. 
Again,  any  case  of  persistent  neuralgia,  in  which 
there  is  a  strong,  neurotic,  inherited  tendency,  is 
unlikely  to  benefit  by  operation. 

A  man,  aged  30,  was  seen  by  Dr.  Henry  Head 
and  myself  on  account  of  severe  pain  in  the  left 
side  of  the  forehead.  It  was  not  typically  epilep- 
tiform, but  came  on  from  time  to  time,  and 
appeared  to  be  situated  in  the  frontal  bone  itself. 
His  wife  stated  that  he  was  strange  in  his  manner 
during  the  attacks  and  she  feared  he  would 
become  homicidal.  The  patient  had  a  dull,  heavy 
expression,  and  the  history  was  that  his  mother 
had  died  insane.  He  had  never  suffered  from 
syphilis,  and  nothing  abnormal  could  be  found  on 
examination  of  the  forehead,  eye,  or  nose.  The 
region  of  the  frontal  sinus  was,  however,  specially 
tender,  and  in  the  hope  that  some  cause  might  be 


42 

found  for  the  neuralgia,  I  trephined  the  anterior 
wall  of  the  sinus  and  thoroughly  explored  it. 
Nothing  abnormal  was  found,  and  the  patient  was 
but  slightly  relieved.  Subsequently  some  opera- 
tion was  performed  by  Mr.  Hunter  Tod  on  the 
upper  cavities  of  the  nose,  but  with  the  same  dis- 
appointing result.  I  saw  the  man  two  years  after 
this,  but  he  was  neither  better  nor  worse,  and  he 
was  dissuaded  from  any  further  operation  ;  I  am 
convinced  that  his  trouble  was  really  cerebral. 

Amongst  the  records  of  operation  on  the  Gas- 
serian  ganglion  are  to  be  found  several  other 
instances  of  "hysterical  neuralgia,"  and  in  every 
one  the  result  was  failure.  Leaving  these  aside, 
a  very  important  question  arises  with  regard  to 
the  genuine  epileptiform  or  major  neuralgia.  It 
has  been  already  noted  that  of  the  three  divisions 
of  the  fifth  nerve  the  superior  and  inferior  maxil- 
lary are  the  most  severely  affected,  and  that  often 
the  pain  is  for  long  periods  confined  to  one  only — 
perhaps  to  a  single  branch  of  them.  This  is 
especially  true  of  the  inferior  dental  and  the  infra- 
orbital nerves.  The  tendency  is  for  the  disease 
to  spread,  but  when  the  neuralgia  has  for  years 
been  practically  confined  to  one  division  it  seems 
only  reasonable  for  the  surgeon  to  limit  his  inter- 
ference to  that  division  or  branch  only.  In  Trous- 
seau's time  such  interference  consisted,  as  a  rule,  in 
a  simple  neurotomy  or  nerve-stretching.  In  many 
of  his    cases   repeated    operations    had    been    done 


43 

on  a  single  patient.  There  is  no  more  candid  or 
masterly  account  of  the  disease  than  is  contained 
in  his  great  work  :  ^  He  sums  up  his  experience 
in  these  words:  "even  now,  after  more  than  thirty- 
six  years  of  practice,  /  have  never  known  it  to  be 
cured  in  a  single  case  radically ^  At  the  same 
time,  in  most  cases,  relief  for  a  few  weeks  or 
months  was  afforded  by  each  operation. 

Prof  Billroth  paid  great  attention  to  the  subject, 
and  in  his  time  resection  of  the  nerves,  and 
operations  on  the  main  branches  nearer  the  base  of 
the  skull  were  practised.  Better  results  were  ob- 
tained, and  it  is  a  most  striking  phenomenon  that 
the  neuralgia  is  in  some  cases  entirely  cured  for  a 
few  years,  but  then  returns  in  aggravated  intensity 
and  widened  area.  In  view  of  such  a  fact,  how  can 
it  possibly  be  true  that  epileptiform  neuralgia  is  due 
to  sclerosis  or  other  gross  change  in  the  Gasserian 
ganglion  or  its  main  branches  ?  Were  that  true, 
an  extracranial  operation,  however  extensive,  could 
have  only  the  most  fugitive  effect  upon  the  pain, 
the  cause  of  which  it  had  not  touched. 

The  following  example  is  quoted  as  being  typical. 
Mugnai^  resected  the  infra-orbital  nerve  in  a  woman, 
aged  seventy-four,  for  severe  neuralgia,  with  relief 
lasting  nearly  three  years ;  then  the  pain  returned 


^  Trousseau's  "  Lectures  on  Clinical  Medicine,"  l^ew.  Syd. 
Soc.  Trans.,  1868,  vol.  i.,  pp.  105  to  116. 
2  Mugnai,  II  Policlinico,  July  15,  1895. 


44 

in  both  second  and  third  divisions  with  great  in- 
tensity. It  rendered  the  patient  half-imbecile,  and 
necessitated  removal  of  the  Gasserian  ganglion. 
Such  a  case  might  be  quoted  by  both  the  advocates 
and  the  opponents  of  extracranial  operation.  The 
first  operation  was  slight,  without  risk  of  life  ;  it 
obtained  comfort  for  the  patient  for  three  years, 
and  did  not  prejudice  the  success  of  the  major  opera- 
tion. On  the  other  hand,  early  resort  to  the  latter 
would  have  saved  the  cruel  disappointment  of  the 
recurrent  pain,  and  the  risk  of  the  patient  be- 
coming a  morphia-habitue.  It  is  most  desirable 
to  consider  the  following  question  without  bias  : — 

To  what  extent  are  peripheral  operations  justi- 
fiable in  severe  trigeminal  neuralgia  ? 

This  question  can  hardly  be  regarded  as  yet 
decided,  and  three  diverse  opinions  are  held  : — 

(i)  Neurectomy  or  avulsion  of  the  affected  nerve 
with  Thiersch's  forceps  should  always  be  given  a 
trial,  since  relief  for  a  period  will  certainly  follow. 

"  The  peripheral  operations  may  be  repeated, 
a  little  more  of  the  nerve  being  removed  at  each 
time. 

"  The  whole  series  of  rational  operations  by 
peripheral  section  should  be  exhausted  before  the 
final  resort  to  intracranial  operations."  ^ 

(2)  Since  anything  more  than  temporary  relief 
from    peripheral    neurectomy    is   quite    exceptional, 

^  J.  B.  Deaver's  "  Surgical  Anatomy,"  vol.  i,  p.  564. 
^  Lauwers  and  van  Geruchten. 


45 

the  greater  number  of  such  operations  should  be 
given  up  entirely.  Persistent  neuralgia,  when  con- 
fined to  one  main  branch  of  the  fifth  nerve, 
especially  the  inferior  dental,  or  the  infra-orbital, 
may  fairly  be  treated  by  peripheral  neurectomy. 

(3)  All  extracranial  operations  on  the  fifth  nerve 
should  be  abandoned  in  favour  of  intracranial 
resection  of  the  Gasserian  ganglion,  its  main  roots 
or  primary  branches. 

In  support  of  either  of  these  alternative  views, 
various  arguments  and  authorities  might  be  ad- 
duced. One  thing  is,  however,  settled — both 
stretching  and  simple  section  of  the  peripheral 
branches  of  the  fifth  nerve  are  practically  worthless, 
and  should  not  be  employed.  It  was  hoped  that 
the  method  of  avulsion,  tearing  put  long  tracts  of 
the  peripheral  branches  as  introduced  by  Thiersch,, 
would  give  better  results  than  the  neater,  and  (to 
use  a  somewhat  discredited  term)  more  surgical 
method  of  careful  excision  of  part  of  the  affected 
nerve.  It  is  remarkable  how  a  nerve  to  its  fine 
terminal  twigs  can  be  pulled  out,  as  shown  by 
many  specimens  figured  by  Krause,  in  his  work  on 
Neuralgia.  Unfortunately,  the  results  obtained  by 
avulsion  with  Thiersch's  forceps  are  little,  if  at  all, 
superior  to  a  well-planned  neurectomy. 

Dr.  Deaver,  who  claims  to  have  had  much  ex- 
perience in  the  treatment  of  tic  douloureux,  argues 
in  favour  of  peripheral  operations,  because  "  the 
period    of   relief  following  any  operation    is    com- 


46 

paratively  speaking,  but  temporary  in  the  majority 
of  cases."  This  argument  is  refuted  entirely  by  the 
results  of  excision,  partial  or  complete,  of  the 
Gasserian  ganglion.  After  such  operations,  the 
period  of  relief  is,  "comparatively  speaking,"  per- 
manent, since  the  patients  are  totally  free  from 
recurrence,  five,  ten,  and  even  more  years  after- 
wards. 

Now  and  then  peripheral  operation  gives  a  lasting 
cure  ;  how  rare  this  is  may  be  judged  from  Prof. 
Billroth's  statement,  that  he  had  never  met  with 
such  a  case,  though  he  had  himself  operated  on 
over  thirty  patients  with  trigeminal  neuralgia.  In 
fact,  cure  by  this  means  is  almost  as  rare  as  spon- 
taneous subsidence,  or  cure  by  drugs.  The  patient 
with  epileptiform  neuralgia,  involving  more  than 
one  division  of  the  fifth  nerve,  has  before  him 
these  alternatives — the  morphia-habit  with  complete 
mental  degradation,  suicide,  or  death  from  exhaus- 
tion. Peripheral  operations,  as  a  rule,  offer  him  only 
temporary  relief,  and  each  recurrence  is  usually 
worse  than  the  last.  Excision  of  the  Gasserian 
ganglion,  is  alone  certain  to  be  followed  by  a 
complete  and  permanent  cure.  These  statements 
are  illustrated  by  the  following  example  : — 

The  patient,  in  the  first  case  I  operated  on,  was  a 
temperate  man,  with  nothing  in  his  previous  history  to 
account  in  any  way  for  the  neuralgia.  The  onset  of  this 
was  in  1882,  when  he  was  42  years  of  age.  The  pain  was 
felt  along  the  lower  jaw  on  the  left  side,  and  for  a  long 
time  the  attacks  were  short  in  comparison   with  the  in- 


47 

tervals  of  freedom  from  the  pain  ;  in  fact,  up  to  1884  these 
intervals  would  amount  to  two  to  three  months,  but  still 
the  neuralgia  was  so  severe  that  he  sought  treatment  for  it 
at  the  hospitals,  and  commenced  to  undergo  a  series  of 
operative  measures. 

(i)  The  teeth  were  removed  from  the  left  side  of  the 
lower  jaw  without  any  benefit. 

(2)  He  was  under  treatment  in  University  College 
Hospital  for  six  weeks. 

(3)  He  went  into  St.  Thomas's  Hospital  in  1884  at  the 
end  of  the  year,  when  Mr.  Pitts  stretched  the  inferior 
dental  nerve.  This  was  followed  by  marked  relief  for 
sixteen  months,  but  in  May,  1886,  the  pain  returned  as 
badly  as  ever. 

(4)  He  was  then  again  in  St.  Thomas's  Hospital  several 
times,  and  had  the  nerve  repeatedly  stretched,  on  one 
occasion  it  is  said  twice  in  forty-eight  hours.  The  pain 
still  continuing  he  went  to  Charing  Cross  Hospital,  where 
neurectomy  was  done  from  inside  the  mouth. 

(5)  The  pain  only  left  him  for  a  month,  and  subse- 
quently spread  to  the  region  of  the  superior  maxillary 
nerve,  and  ultimately  to  the  back  of  the  head  ;  its  severity 
increased,  the  intervals  became  shorter,  and  after  eight 
years'  endurance  of  the  suffering  he  sought  further  relief 
from  operation. 

(6)  In  March,  1895,  Sir  F.  Treves  removed  Meckel's 
ganglion  and  the  infra-orbital  nerve  by  opening  up  and 
following  the  roof  of  the  antrum  of  Highmore.  He  was 
then  relatively  free  from  pain  for  four  months,  but  in  the 
autumn  of  1895  he  was  compelled  to  take  morphine  in 
considerable  doses  to  get  any  relief.  From  January,  1890, 
to  September  of  the  next  year  he  was  a  complete  wreck 
from  attacks  of  pain  and  spasm,  and  to  a  lesser  extent 
from  the  narcotic  and  sedative  drugs  that  were  given  to 
him. 

(7)  On  October  i,  1897,  the  final  operation,  removal  of 
the  Gasserian  ganglion,  was  performed.  Before  alluding 
to  this  operation,  we  must  note  some  further  details  as  to 


48 

the  neuralgia.  The  spasms  of  pain  were  accompanied  by- 
convulsive  movements  of  the  depressors  of  the  lower  jaw, 
and  of  the  facial  muscles  on  the  left  side.  These  attacks 
of  spasmodic  pain  ultimately  came  on  with  great  regularity, 
the  intervals  being  sometimes  only  half  a  minute  or  a 
minute. 

Although  he  thought  the  pain  was  worse  in  damp 
weather,  no  other  condition  could  be  noticed  to  have  any 
effect  in  producing  or  intensifying  the  pain ;  for  instance, 
neither  taking  alcohol,  nor  smoking,  neither  exposure  to 
the  heat  of  a  fire  nor  to  the  cold  of  a  dry  frost  had  any  special 
effect.  The  attacks  of  pain  came  on  as  often  when  he  was 
resting  in  bed  as  when  he  was  up,  but  they  completely 
incapacitated  him  from  work.  His  memory  for  all  recent 
events  was  very  defective,  and,  of  course,  from  pain  and 
sleeplessness  he  was  reduced  to  a  miserably  depressed  con- 
dition ;  he  was  for  some  time  of  marked  suicidal  tendency. 

The  onset  of  each  attack  was  most  sudden  ;  his  head 
would  be  turned  to  the  left,  his  mouth  widely  opened,  and 
his  left  hand  pressed  to  the  cheek  in  a  vain  effort  to  get 
some  relief  from  the  pain.  There  was  no  true,  superficial 
tenderness,  and  the  only  patch  of  anaesthesia  extended 
from  just  below  the  V-shaped  scar  on  the  front  of  the 
cheek,  made  in  the  removal  of  Meckel's  ganglion,  down  to 
the  red  margin  of  the  upper  lip.  Inside  the  mouth  the 
pain  was  felt  as  badly  as  ever  along  the  lower  jaw,  in  spite 
of  the  repeated  operations  on  the  inferior  dental  nerve,  and 
the  left  lower  lip  and  the  left  side  of  the  tongue  (except  at 
the  top)  were  involved.  It  is  unnecessary  to  say  that  all 
the  known  sedatives  had  been  tried,  but,  with  the  exception 
of  morphine,  none  were  of  any  material  use,  and  the  large 
doses  of  this  drug  required,  caused  delusions,  and  much 
depressed  him. 

A  flap  being  turned  down  from  the  temporal  fossa,  with 
its  base  at  the  zygoma,  and  the  temporal  vessels  being 
secured,  the  greater  part  of  the  squamous  portion  of  the 
bone  was  removed  by  trephine  and  cutting  forceps,  without 
injuring  the  dura  mater  or  the  branches  of  the  middle 
meningeal  artery. 


49 

The  temporo-sphenoidal  lobe  with  the  dura  mater  was 
then  gradually  lifted  up  from  the  middle  fossa,  until  the 
foramen  spinosum  was  reached.  The  onlj'  difficulty  so 
far  had  been  venous  oozing  from  numerous  minute  vessels 
in  dura  mater  and  bone.  An  aneurism  needle  was  passed 
round  the  middle  meningeal  artery,  and  considerable 
trouble  was  experienced  in  effecting  the  double  ligature 
and  division  of  this  vessel,  owing  to  the  depth  of  the 
foramen  spinosum  from  the  surface  (a  little  over  two  inches). 
The  venous  oozing  was  so  troublesome  that  it  was  con- 
sidered impossible  to  expose  the  ganglion  on  that  day, 
and  the  second  part  of  the  operation  was  therefore  deferred 
for  a  week.  On  the  second  occasion  the  flap  of  skin  and 
muscle,  which  had  been  sewn  in  place,  was  readily  detached 
from  the  dura  mater,  and  after  again  raising  the  temporo- 
sphenoidal  lobe  with  a  specially-designed  broad  retractor, 
the  foramina  ovale  and  rotundum  were  exposed,  and  the 
superior  and  inferior  maxillary  division  of  the  fifth  nerve 
completely  divided.  Prior  to  this,  the  dura  covering  over 
the  Gasserian  ganglion  was  lifted  up  from  it  until  the 
upper  border  of  the  ganglion  and  the  trunk  nerve  were 
reached. 

The  ganglion  was  removed  in  one  piece.  It  was  thought 
at  the  time  that  the  ophthalmic  division,  which  is,  of  course, 
much  the  smallest  of  the  three,  had  been  divided  and 
removed  with  the  ganglion,  but  the  result  showed  that  this 
could  not  have  been  the  case,  since  the  patient  retained 
sensation  in  the  supraorbital  and  nasal  nerves.  However, 
the  escape  of  the  ophthalmic  nerve,  which  was  due  to  one's 
anxiety  not  to  injure  the  cavernous  sinus  or  the  oculo- 
motor nerves  (an  accident  which  has  occurred  in  some  of 
the  recorded  cases)  had  no  bad  effect  upon  the  after-result. 
From  the  date  of  the  operation  up  till  now  (a  period  of 
thirteen  months)  the  patient  has  had  no  return  of  pain. 
He  has  got  back  to  constant  work,  having  been  incapa- 
citated for  some  years.  Occasionally  there  is  slight 
twitching  of  some  of  the  left  facial  muscles,  but  this  is 
painless  and  is  hardly  an  inconvenience.  The  anaesthesia 
4 


50 

in  the  distribution  of  the  superior  and  inferior  maxillary 
nerves  only  gives  him  trouble  when  particles  of  food  get 
down  between  the  tongue  and  the  jaw,  or  the  jaw  and  the 
cheek.  It  is  of  interest  to  note  that  the  sense  of  taste  as 
regards  quinine,  salt,  &c.,  is  lost  on  the  left  side  of  the 
tongue  (dorsum),  as  also  that  of  sensation  to  heat  and  cold 
and  tactile  impressions.  It  is  needless  to  say  that  his  left 
temporal,  masseter,  and  pterygoid  muscles  are  paralysed 
and  have  become  atrophic,  but  he  seems  to  be  singularly 
little  inconvenienced  by  this,  and  never  complains  of  any 
difficulty  in  mastication.  It  may  be  noted  that  he  had, 
like  so  many  of  the  cases  of  trigeminal  neuralgia,  lost  the 
teeth  on  the  affected  side  long  prior  to  the  operation.  The 
aperture  in  the  bone  forming  the  temporal  fossa  has  been 
almost  entirely  closed  up,  so  that  pulsation  cannot  be  felt 
and  the  scar  has  to  be  sought  for. 

The  foregoing  account  has  been  largely  based  on  Dr. 
Head's  admirable  notes  of  the  case. 

Microscopic  examination  of  the  ganglion  and  the  nerve 
trunks  leading  from  it  did  not  reveal  any  marked  abnor- 
mality in  the  ganglion  cells  or  the  nerve  fibres,  but  there 
appeared  to  be  great  overgrowth  of  fibrous  tissue  through- 
out the  ganglion  ;  the  arterioles  in  the  latter,  though 
imbedded  in  this  dense  fibrous  tissue,  presented  no  signs 
of  disease  of  their  walls. 

(Note  in  1904). — The  patient  has  continued  free  from 
the  slightest  return  of  neuralgia.  It  is  now  seven  years 
since  the  operation. 

As  the  preceding  case  shows,  when  once  the 
neuralgia  has  spread  from  one  division  of  the  nerve 
to  another,  it  is  useless  to  waste  time  over  extra- 
cranial operations  ;  but  a  patient  with  the  disease 
confined  to  e.g.,  the  inferior  dental  nerve  will  hardly 
consent  to  undergo  the  major  operation  on  the 
Gasserian  ganglion,  unless  more  limited  interference 


51 

has  failed.  The  following  account  deals  with  what 
seem  to  be  the  best  of  these  operations.  At  the 
same  time  a  number  of  methods,  elaborate,  and 
most  of  them  disfiguring,  which  have  filled  such  an 
irnposing  place  in  surgical  text-books,  are  entirely 
omitted.  If  the  majority  of  extracranial  methods 
of  neurectomy  of  the  fifth  nerve  were  forgotten,  it 
would  be  to  the  advantage  of  both  surgeon  and 
patient.  The  extracranial  operations  to  be  des- 
cribed relate  to  (i)  the  inferior  dental  nerve,  and 
(2)  the  superior  maxillary  division.  Intracranial 
neurectomy  of  the  two  main  divisions  will  also  be 
briefly  described. 

I. —  The  Inferior  Dental  Nerve. 

The  intrabuccal  method  was  introduced  by  Para- 
vicini  (of  Italy),  in  1858.  The  mouth  is  widely' 
opened  by  a  gag  fixed  on  the  opposite  side,  the 
cheek  being  held  back  by  a  retractor ;  the  operator, 
with  his  left  index  finger,  feels  for  the  anterior 
edge  of  the  ascending  ramus,  and  tracing  this 
upwards  and  backwards  reaches  the  "spine  of 
Spix."  An  incision  of  nearly  an  inch  through 
mucous  membrane,  internal  pterygoid  muscle,  and 
spheno-maxillary  ligament  enables  the  inferior  dental 
nerve  to  be  discovered  and  resected.  It  is  well 
to  trace  the  nerve  into  the  inferior  dental  foramen 
so  as  to  make  sure  that  the  gustatory  nerve  (which 
lies  near  and  in  front  of  the  other  trunk)  be  not 
mistaken    for    it.     Care    must    be    taken    not    to 


52 

wound  the  inferior  dental  artery.  The  operation 
is  performed  in  an  awkward  corner  of  the  mouth, 
but  the  alternative  method  proposed  by  Monte- 
noveri  is  infinitely  more  difficult.  He  advocates 
an  incision  through  the  skin,  which  commences 
at  the  angle  of  the  jaw  and  runs  forward  parallel 
to  the  lower  border  until  the  facial  artery  is  reached. 
With  knife  and  periosteal  elevator  the  internal 
pterygoid  muscle  is  detached  inwards,  and  the 
operator  ultimately  reaches  the  spine  of  Spix  and 
the  inferior  dental  nerve.  The  sole  advantage 
lies  in  the  fact  that  the  buccal  mucous  membrane 
is  not  divided.  Both  methods  are  inferior  to  the 
following : — 

Neurectomy  of  the  Inferior  Dental  Nerve 
through  a  trephine  aperture  in  the  lower  jaiv. 
— The  point  of  bone  to  be  aimed  at  is  indicated 
on  the  ascending  ramus  by  the  meeting  of  two 
lines — one  perpendicular  to  the  lower  border  of 
the  jaw  passing  upwards  from  its  angle,  the  other 
a  continuation  backwards  of  the  alveolar  margin. 
This  point  on  the  side  of  the  cheek  is  well  below 
the  parotid  duct  and  behind  the  facial  vein ;  the 
skin  incision  of  one  inch  should  be  mainly  hori- 
zontal, to  avoid  injury  to  the  facial  nerve,  but  it 
is  convenient  to  curve  it  slightly.  The  masseter 
being  exposed,  its  fibres  are  partly  severed,  but 
chiefly  separated,  until  the  bone  is  reached  and 
bared  with  a  periosteal  elevator.  The  pin  of  a 
small  (half-inch)   trephine   is  then   inserted  exactly 


S3 

at  the  spot  above-mentioned,  and  when  the  outer 
table  of  compact  bone  is  traversed,  the  disc  is 
removed  by  means  of  the  elevator.  It  is  almost 
certain  that  the  groove  containing  the  inferior 
dental  nerve  and  vessels  will  be  opened  thereby, 
and  it  should  very  carefully  be  cleared  on  either 
side  with  a  small  chisel  or  bone-cutting  forceps. 
The  groove  should  be  followed  upwards  and  down- 
wards, with  due  caution  not  to  injure  the  inferior 
dental  artery,  until  the  nerve  can  be  raised  along 
on  a  hook.  With  Thiersch's  forceps  a  long  piece 
of  both  ends  of  the  divided  nerve  can  sometimes 
be  drawn  out ;  if  not,  as  much  should  be  cut  away 
as  possible.  The  bone  disc  need  not  be  replaced, 
and  two  or  three  fine  sutures  will  suffice  for  the 
wound,  which  heals  rapidly.  The  patient  should 
be  kept  on  liquid  or  soft  food  for  a  few  days. 

The  success  of  the  operation  depends  chiefly  on 
following  the  landmark  given  exactly,  and  avoid- 
ing injury  to  the  companion  artery.  As  a  rule, 
the  dental  nerve  lies  just  in  front  of  the  latter, 
and  is  readily  distinguished,  once  the  canal  is 
opened,   by  its  whiter  colour. 

After  this  neurectomy  the  pain  is,  as  a  rule, 
entirely  absent  for  one,  two,  or  more  years,  but  it 
is  exceptional  for  no  recurrence  of  any  kind  to  be 
experienced.  It  may  be  noted  that  immediately 
after  the  operation,  for  a  few  days,  the  patient 
will  complain  of  aching,  due  to  the  traction  of 
the  proximal   end.     The   method   and   the   amount 


54 

of  relief  that  is  to  be  expected  from  it  is  illus- 
trated by  the  following  case  : — 

Samuel  G.,  a  florid,  healthy- looking  man,  before 
the  onset  of  neuralgia  had  been  a  free  liver  and 
suffered  from  slight  symptoms  of  gout.  He  had 
Dupuytren's  contraction  of  the  ring  finger  in  each 
hand.  His  father  and  one  brother  were  said 
to  have  died  from  gout.  At  the  age  of  59  the 
right,  inferior,  dental  nerve  became  the  site  of 
severe  neuralgia,  for  which  all  the  teeth  were 
removed  from  the  lower  jaw  behind  the  incisors 
on  the  right  side.  No  relief  was  obtained.  A 
year  later  Mr.  Stanley  Boyd  performed  an  opera- 
tion on  the  inferior,  maxillary  division  just  below 
the  foramen  ovale.  The  pain  was  relieved  for 
about  twelve  months,  but  it  returned  with  increas- 
ing frequency  of  the  attacks  until  it  was  almost 
continuous  both  night  and  day.  The  pain  was 
especially  severe  over  the  right  mental  foramen, 
causing  reflex  spasm  of  the  facial  and  masticatory 
muscles.  He  obtained  some  relief  by  violently 
pinching  the  skin  over  the  lower  jaw,  this  be- 
coming a  constant  habit. 

As  the  neuralgia  was  confined  to  the  inferior  dental 
nerve  it  did  not  seem  to  justify  operation  on  the  Gas- 
serian  ganglion,  and  on  September  7,  1899,  I  re- 
sected the  inferior,  dental  nerve,  after  trephining 
through  the  outer  part  of  the  ascending  ramus  of  the 
lower  jaw.  The  nerve  was  exposed  without  diffi- 
culty, and  about  one  inch  of  it  was  removed ;  the 


55 

nerve  was  quite  normal.  For  a  week  after  the 
operation  the  pain  continued  as  bad  as  before, 
but  it  gradually  left  him  and  he  was  free  for 
eighteen  months,  when  it  returned  with  increasing 
intensity,  involving  the  right  cheek  and  both  jaws  ; 
the  neuralgia  was  occasionally  referred  to  the  eye. 
Medicines  failed  entirely  to  relieve  him,  and  the 
patient  got  into  a  miserable  condition,  almost 
unable  to  sleep,  or  to  take  food  without  bringing 
on  spasms  of  pain.  On  more  than  one  occasion 
he  threatened  suicide. 

On  October  8,  1901,  the  right  Gasserian  gan- 
glion was  operated  on  by  the  temporal  route. 
The  patient  had  emphysema  and  pulmonary  con- 
gestion at  the  bases,  and  was  therefore  a  bad 
subject  for  an  anaesthetic.  A.C.E.  was  carefully 
administered,  with  the  patient  sitting  in  a  dental 
chair,  but  owing  to  respiratory  trouble  it  was 
found  necessary  once  or  twice  to  lower  him  to 
the  horizontal  position.  I  removed  a  circular 
area  of  bone  about  three  inches  in  diameter  with 
the  trephine  and  cutting  forceps,  and  succeeded  in 
exposing  the  ganglion  without  dividing  the  middle 
meningeal  artery  ;  the  lower  half  of  the  ganglion, 
or  rather  more,  with  the  superior  maxillary  divi- 
sion, was  completely  removed.  Venous  haemor- 
rhage caused  some  trouble.  No  bone  was 
replaced,  the  drainage  tube  being  removed  on  the 
second  day  ;  the  wound  healed  perfectly,  and  the 
patient    left    the    hospital    three    weeks    after    the 


56 

operation.  For  over  two  years  he  has  continued 
in  excellent  health  being  now  66  years  old,  and 
there  has  not  been  the  slightest  return  of  pain.  He 
takes  too  much  stimulant — a  bottle  of  champagne 
a  day — but  considers  himself  entitled  to  it,  after 
what  he  had  gone  through.  The  area  of  anaes- 
thesia, as  shown  in  fig.  20,  includes  the  whole  of 
the  cheek,  the  temporal  region  and  both  lips  to 
the  middle  line,  as  well  as  the  ala  of  the  nose. 
He  masticates  very  well,  in  spite  of  the  atrophy 
of  the  masseter,  pterygoids,  and  temporal  muscles 
on  the  side  operated  on. 

Note. — Early  in  1904,  that  is,  nearly  three 
years  after  the  operation,  the  patient  died.  His 
son  stated  that,  so  far  as  the  neuralgia  was  con- 
cerned, he  had  remained  quite  free  from  any 
return. 

Dr.  Ewing  Mears  performed  a  somewhat  similar 
operation  in  1883,  only  he  trephined  the  outer  table 
of  the  jaw  about  the  mental  foramen,  and  then  drew 
out  some  three  inches  of  the  nerve.  His  case  was 
free  from  recurrence  at  the  end  of  nine  months, 
though  it  is  probable  that  the  neuralgia  returned 
later. 

The  operation  on  the  inferior  dental  nerve  just 
described  is  easy  to  perform  ;  it  leaves  no  deformity, 
and  is  worth  doing  in  any  case  of  persistent 
neuralgia  starting  in  the  lower  jaw.  The  patient 
should,  however,  be  told  that  whilst  there  is  a 
chance  of  permanent  recovery,   the   relief  is  more 


T.N. 


A.T.'S. 


B.N. 


'-J  I.D.N. 


G.N. 


M.II.N. 


Fig.  7. 

The  main  branches  of  the  inferior  maxillary  division,  from  a  dissection  in 
the  London  Hospital  Museum.  Z. — The  zygoma,  cut  at  each  end  and 
removed.  T.N. — Motor  branches  to  the  temporal  muscle.  A.T.N. — Auri- 
culo-temporal  nerve.  B.N. — Buccal  nerve,  joining  in  a  plexus  with  branches 
of  the  facial  nerve  to  the  buccinator  muscle.  I.D.N. — Inferior  dental  nerve. 
G.N. — Gustatory  or  lingual  nerve,      M.H.N. — Its  mylohyoid  branch. 


57 

likely  to  be  for  a  year  or  two  only,  and  that  in  the 
case  of  recurrence  a  more  radical  operation  can  be 
done  on  the  Gasserian  ganglion. 

This  is  the  only  peripheral  operation  on  the  third 
division  of  the  fifth  nerve  that  can  be  really 
recommended.  Neurectomy  of  the  gustatory  nerve 
is  hardly  worth  discussing ;  it  has  occasionally  been 
practised  for  the  pain  of  cancer  of  the  tongue,  but 
the  procedure  has  fallen  into  disuse.  As  to  the 
formidable  methods  of  approaching  the  third  divi- 
sion just  below  the  base  of  the  skull,  surgery  will 
gain  by  their  complete  abandonment.  They  almost 
all  involve  division  of  zygoma  and  coronoid  process, 
and  owing  to  haemorrhage  and  the  deep  awkward 
wound,  the  operations  are  extremely  prolonged  and 
difficult.  The  results  are  very  poor,  since  move- 
ments of  the  jaw  are  usually  limited,  an  ugly  scar 
being  left  on  the  face,  and  the  neuralgia  quickly 
returns.  If  operation  is  indicated  upon  the  third 
division  alone,  the  intracranial  method  should  cer- 
tainly be  preferred.  Some  may  think  this  con- 
demnation of  the  many  elaborate  methods  alluded 
to  somewhat  sweeping,  but  experience  will  probably 
show  that  it  is  right. 

II. — The  Superior  Maxillary  Nerve. 

In  order  to  avoid  the  disfiguring  division  of  bone 
required  by  the  ordinary  methods  of  excising  the 
superior  maxillary  nerve  in  the  pterygo-maxillary 
fossa,  M.  Poirier^  brought  forward  a  new  method. 

^  Poirier,  Bull,  et  mem  de  la  soc.  dn  chir.,  t.  xxv.,  p.  414. 


58 

It  consists  briefly  in  two  steps  :— (i)  the  infra- 
orbital nerve  is  exposed  on  the  front  of  the  face  just 
below  the  foramen,  is  divided,  and  a  silk  ligature 
put  round  its  proximal  end.  (2)  A  vertical  incision, 
one  centimetre  behind  the  junction  of  the  malar 
bone  with  the  orbital  margin,  is  made,  and  steadily- 
deepened  through  the  temporal  muscle.  Down  in 
the  hollow,  the  superior  maxillary  trunk  is  ex- 
posed (!)  and  seized  with  forceps.  Traction  is  made 
so  as  to  draw  the  whole  nerve  out  from  the  upper 
jaw  bone,  as  far  forwards  as  the  ligature. 

There  are  two  strong  objections  to  the  method : 
(i)  the  depth  of  the  incision  and  the  bleeding 
render  it  almost  impossible  to  make  sure  of  the 
nerve  ;  and  (2)  even  if  it  be  secured  in  the  forceps, 
it  may  be  impossible  to  draw  the  peripheral  part 
outwards. 

Carnochan's  method  of  reaching  the  pterygo- 
maxillary  fossa  from  the  front  by  trephining  both 
walls  of  the  antrum  of  Highmore,  and  following 
back  the  infra-orbital  nerve  in  its  roof  is  well- 
known.  Many  examples  have  been  recorded  by 
Mr.  Chavasse  ^  and  Sir  Frederic  Treves.^  It  is  a 
difficult  operation,  and  the  neuralgia  almost  always 
returns  after  an  interval  varying  from  a  few  months 
to  a  year  or  two. 

The  following  account  is  taken  from  the  second 

^  Chavasse,  Medico-Chirurgical  Soc.  Transactions,  1884. 

^  Sir  F.  Treves,  "Operative  Surgery,"  1904,  vol.  i.,  p.  209. 


59 

edition  of  the  Operative  Surgery,  revised  by  Sir  F. 
Treves  and  myself. 

"A  V-shaped  incision  is  made  on  the  front  of  the 
cheek,  so  placed  that  the  apex  points  directly  down- 
wards, and  the  centre  of  the  V  is  opposite  to  the 
infra-orbital  foramen.  The  incision  should  form 
two  sides  of  an  equilateral  triangle,  each  limb  of 
which  measures  a  little  more  than  one  inch. 

"  The  knife  is  carried  at  once  down  to  the  bone, 
and  the  triangular  flap  formed  by  the  soft  parts  is 
turned  up  over  the  lower  lid.  A  long  silk  suture  is 
introduced  into  the  apex  of  the  flap,  in  order  that 
it  may  be  drawn  well  upwards  out  of  the  surgeon's 
way. 

"  The  infra-orbital  nerve  is  sought  for  and  isolated 
as  it  is  emerging  from  the  foramen.  The  bone 
having  been  cleared,  a  portion  of  the  anterior  wall, 
of  the  antrum  measuring  from  half  to  three-quarters 
of  an  inch  square  is  removed  with  a  chisel  and 
mallet.  The  infraorbital  foramen  will  be  a  little 
above  the  centre  of  the  part  removed.  The  mucous 
lining  of  the  antrum  having  been  divided,  that  cavity 
is  fully  opened.  In  order  that  the  rest  of  the 
operation  may  be  conveniently  performed,  a  small 
electric  lamp  is  needed,  which  may  be  fixed  to  the 
surgeon's  forehead.  In  no  operation  is  a  good 
light  more  essential. 

"  The  posterior  wall  of  the  antrum  is  now  exposed, 
and  a  portion  about  a  quarter  of  an  inch  square  is 
cut  away  with  a  fine  chisel  and  mallet. 


6o 

"  In  removing  the  two  portions  of  bone  some 
surgeons  use  trephines — a  half-inch  trephine  for  the 
anterior  wall  and  a  quarter-inch  for  the  posterior. 
The  chisel  is,  however,  by  far  the  more  convenient 
and  precise  instrument,  and  inflicts  a  less  degree  of 
injury  upon  the  surrounding  tissues. 

"The  haemorrhage  is  very  free,  and  some  little 
time  may  now  be  devoted  to  arresting  it  as  far  as  is 
possible, 

"  The  next  step  consists  in  dividing  the  mucous 
hning  on  the  roof  of  the  antrum,  under  the  course 
of  the  infra-orbital  canal.  The  bone  forming  the 
floor  of  this  canal  must  be  broken  away  from  one 
end  of  the  maxilla  to  the  other.  This  is  best 
effected  by  means  of  scissors,  aided  by  a  fine, 
carpenter's  bradawl  and  a  slender,  bone  elevator  or 
stout  director..  The  bone  is  thin  and  offers  little 
resistance,  and  the  nerve,  which  must  be  mos,t  care- 
fully preserved  and  carefully  followed  line  by  line, 
forms  the  guide  to  the  surgeon's  movements. 
Much  bleeding  may  be  expected  from  the  damaged 
infra-orbital  vessels,  which  can  seldom  be  surely 
isolated.  When  the  posterior  wall  of  the  maxilla  is 
reached,  the  white  and  conspicuous  nerve  will  be 
hanging  loose  in  the  cavity  of  the  antrum.  Slender 
dissecting  forceps  with  long  blades  are  needed 
during  this  stage,  and  become  still  more  necessary 
when  the  rea^ion  of  the  foramen  rotundum  is 
reached. 

"  The  bone  of  the  hinder  wall  of  the  antrum  must 


6i 

be  so  completely  removed  that  the  nerve  is  seen  to 
hang  free  in  the  cavity  produced.  The  wound  may 
now  be  stuffed  for  a  while  with  a  conical  piece  of 
sponge,  in  order  that  the  haemorrhage,  which  is  still 
free,  might  be  held  a  little  in  check. 

"  By  means  of  the  long,  slender  forceps  and  a 
director,  the  surgeon  endeavours  to  make  out  the 
position  of  the  trunk  as  it  issues  from  the  foramen 
rotundum,  and,  if  possible,  the  precise  locality  of 
the  ganglion.  In  this  attempt  he  is  aided  by  the 
infra-orbital  nerve,  upon  which  traction  (by  means 
of  a  silk  thread),  is  maintained.  Finally,  the 
superior  maxillary  nerve  is  divided  close  to  the 
foramen  rotundum  by  a  pair  of  very  slender,  curved 
scissors,  and  any  branches  which  still  hold  the  nerve 
in  position  having  been  divided,  the  whole  trunk  is 
removed  with  the  ganglion  attached. 

"  At  this  step  of  the  operation  also  much  bleeding 
may  be  expected.  The  nerve  cord  removed  should 
measure  not  less  than  one-inch  and  three-quarters. 

"  The  antrum  having  been  sponged  out,  the  skin 
incision  is  united  by  sutures  and  the  selected 
dressing  applied.  A  small  drainage  tube  should  be 
maintained  in  the  lower  angle  of  the  wound  for  the 
first  twenty-four  hours." 

If  an  extracranial  operation  is  to  be  performed  on 
the  superior  maxillary  division,  probably  the  best 
method  is  one  which  is  attributed  to  an  American 
surgeon  named  Storrs.  It  is  described  by  Dr. 
Cook  in  the  "  Annals  of  Surgery,"  1903,  vol.  xxxvii., 


62 

p.  854.  It  has  the  merit  of  leaving  only  an  incon- 
spicuous scar  on  the  face.  The  following  descrip- 
tion is  in  Dr.  Cook's  own  words : 

"  Place  the  patient  half  reclining  in  a  chair, 
wedged  with  sand-bags.  The  operator  seats  him- 
self on  a  stool  facing  the  patient,  on  the  side  of 
the  eye  on  which  he  intends  to  operate.  One 
assistant  is  necessary  to  give  the  anaesthetic,  and 
a  second  to  hold  the  retractor.  The  lower  edge 
of  the  orbit  can  be  easily  felt  through  the  skin. 
Make  a  clean  incision  along  this  edge,  from  the 
inner  to  the  outer  angle  of  the  orbit,  through  the 
tissues,  including  the  periosteum,  down  to  the  bone. 
Then  with  a  blunt  instrument  carefully  elevate 
the  periosteum  from  the  floor  of  the  orbit,  going 
well  back  and  exposing  the  spheno-maxillary  fissure. 
Lift  the  eyeball  out  of  the  way  with  a  spoon- 
shaped  retractor  inserted  under  the  periosteum. 
Usually  a  bluish  spot  will  appear,  showing  the 
situation  of  the  infra-orbital  nerve,  covered  by  a 
thin  plate  of  bone,  in  its  canal  in  the  floor  of  the 
orbit.  Should,  however,  there  be  any  difficulty  in 
locating  the  nerve,  it  can  easily  be  done  by  passing 
a  probe  into  the  infra-orbital  foramen  and  up  into 
the  orbit.  Having  located  the  nerve,  with  a 
chisel  or  any  suitable  instrument  remove  the  thin 
plate  of  bone  covering  it.  The  nerve  can  then 
be  easily  hooked  up  and  brought  to  view.  The 
infra-orbital  artery  is  usually  torn  at  this  time  and 
bleeds  for  a  few  moments,  but  it  is  of  no  import- 
ance, and  will  soon  take  care  of  itself. 


63 

"  Having  hooked  up  the  nerve,  ligate  it  securely 
with  a  piece  of  silk  passed  around  it  with  an 
aneurism  needle.  Then  cut  the  nerve,  leaving 
the  ligature  fastened  to  the  proximal  end  of  the 
cut  nerve.  We  now  have  the  nerve  under  perfect 
control.  By  making  a  slight  traction  on  the  liga- 
ture we  can  bring  the  nerve  into  view,  and  by 
following  it  on  can  readily  crush  down  the  thin 
wall  of  the  canal,  removing  the  bone  fragments 
with  suitable  forceps.  When  the  nerve  enters  the 
spheno-maxillary  fissure  it  passes  out  of  the  bony 
canal  and  is  only  surrounded  by  soft  structures, 
which  can  easily  be  hooked  or  wiped  away. 
Should  the  spheno-maxillary  fissure  be  narrow  and 
not  readily  admit  the  introduction  of  instruments,  it 
can  easily  be  widened  by  inserting  a  suitable,  blunt 
instrument  and  by  wedging  or  widening  the  walls. 
It  is  remembered  that  the  upper  wall  of  this 
fissure  is  the  strong  wing  of  the  sphenoid  bone, 
and  that  the  lower  angle  is  the  thin  wall  of  the 
antrum.  If  either  bone  should  break  in  these 
manipulations  it  would  be  the  wall  of  the  antrum 
which  would  be  crushed  down  and  out  of  the  way 
and  would  cause  no  trouble.  Havingf  the  nerve 
thus  free  to  the  foramen  rotundum,  next  slip  the 
ends  of  the  silk  ligature  through  a  loop  of  wire 
held  with  a  small  snare  (the  Jarvis  snare  of  the 
rhinologists).  The  loop  of  wire  in  the  snare  is 
passed  down  the  nerve  to  the  foramen  rotundum, 
just    as   a  tunnel   sound   is  passed    over   a   filiform 


64 

bougie.  When  the  loop  of  wire  reaches  the 
foramen  rotundum  it  is  closed,  and  the  nerve  is 
cut  and  removed. 

.  "  To  return  now  to  the  distal  end  of  the  nerve. 
Separate  the  integument  from  the  bone  down  to 
the  infra-orbital  foramen,  gather  up  with  a  hook 
the  mxesh  of  nerves  going  to  the  cheek  and 
drag  the  divided  nerve  through  the  foramen. 
Storrs  then  put  the  nerve  into  the  loop  of  a 
threaded  needle  and  carried  it  down  into  the 
mouth,  leaving  the  end  which  had  been  in  the 
infra-orbital  canal  suspended  between  the  alveolus 
and  the  upper  lid  ;  this  end  he  cut  off  even  with 
the  mucous  membrane.  This  was  for  the  purpose 
of  preventing  any  possible  restoration  of  any  com- 
munication between  the  peripheral  branches  of  the 
nerve  and  the  stump  left  at  the  foramen  rotundum. 
To  complete  the  operation,  place  a  small  gutta- 
percha-tissue  drain  in  the  track  of  the  nerve,  ex- 
tending from  near  the  foramen  rotundum  to  the 
surface  ;  suture  the  skin  wound.  The  drain  should 
be  removed  at  the  end  of  twenty-four  hours." 

It  is  stated  that  Dr.  Storrs  operated  by  his 
method  on  some  ten  or  twelve  patients,  and  that 
of  these  at  least  two  remained  free  from  neuralgia 
for  over  ten  years.  This  is  an  unusually  favour- 
able result  from  any  form  of  peripheral  operation. 
At  the  same  time  it  must  be  uncertain  whether 
the  central  end  of  the  nerve  is  divided  beyond 
its  branches  to  the  palate  and  molar  teeth. 


65 

Further  experience  must  prove  whether  the 
intracranial  excision  of  the  superior  maxillary  divi- 
sion (see  page  71)  or  Storrs'  operation  is  the 
better.  The  former  is,  perhaps,  the  more  severe, 
and  certainly  the  more  radical  of  the  two.  I 
think  Carnochan's  method  will  be  entirely  aban- 
doned, and  Poirier's  is  not  practical.  It  would  be 
both  tedious  and  unprofitable  to  quote  descrip- 
tions of  the  many  ingenious  variations  of  the 
operation,  to  which  different  surgeons'  names  have 
been  attached.  They  are  at  least  a  dozen  in 
number,  and  most  of  them  involve  an  extensive 
osteoplastic  operation  on  the  outer  orbital  wall, 
the  zygoma,  or  the  upper  jaw. 

"  Mugnai's  operation  "  may  be  briefly  mentioned 
from  amongst  these.  A  nearly  rectangular  incision 
is  made  along  the  upper  border  of  the  zygoma,' 
forwards  to  the  outer  orbital  edge,  and  then  down- 
wards towards  the  last  molar  tooth  over  the  anterior 
edge  of  the  malar  bone.  The  orbital  contents 
are  pushed  upwards  and  inwards  until  the  spheno- 
maxillary fissure  is  reached  ;  with  a  wire  saw  the 
malar  bone  is  sawn  through  in  two  directions, 
back  into  the  temporal  fossa  and  downwards  at  its 
junction  with  the  superior  maxilla.  The  zygoma 
is  chiselled  through  and  the  malar  bone  turned 
downwards.  The  subsequent  steps,  following  back 
the  infra-orbital  nerve  towards  the  foramen  rotun- 
dum,  &c.,  need  not  be  described. 

This  method,  like  so  many  others,  involves  a  scar 
5 


66 

on  the  face,  and  what  is  more  important,  an  elabo- 
rate division  of  bone,  which  may  not  unite  again 
well,  and  may  even  necrose.  It  hardly  gives  any 
better  access  to  the  superior  maxillary  nerve  than 
Storrs'  simple  incision  at  the  lower  edge  of  the 
orbit ;  and  as  regards  the  clean  excision  of  the 
nerve  trunk  does  not  compare  with  the  intracranial 
method  described.  The  term  "  Storrs'  method  "  has 
been  used  with  reserve,  priority  of  description  or 
invention  in  these  matters  being  most  uncertain. 
Professor  Billroth  was  in  the  habit  of  employing  a 
similar  incision  along  the  floor  of  the  orbit,  and 
mentions  at  least  one  case  in  which  he  tracked 
the  superior  maxillary  division  "  back  to  the 
foramen  rotundum." 

It  will  be  convenient  to  summarise  the  various 
forms  of  operation,  and  to  indicate  which  are  the 
best  to  follow  : — 

(i)  Intracranial  resection  by  trephining  the  wall 
of  the  temporal  fossa  (see  page  71).  By  this 
method  alone  the  nerve  is  excised  before  it  has 
given  off  any  branches  ;  it  is  certainly  the  most 
radical  and  promising. 

(2)  The  infra-orbital  method : — following  this 
nerve  back  along  the  floor  of  the  orbit  to  the 
pterygo  -  maxillary  fossa.  Very  little  bone  is 
divided,  and  the  scar  is  not  conspicuous. 

(3)  Trephining  the  antrum  of  Highmore  to 
reach  the  pterygo  -  maxillary  fossa  (Carnochan's 
method).     This  should  be  given  up. 


67 

(4)  Resection  of  the  outer  wall  of  the  orbit 
(Mugnai's  method).  This  has  no  advantages  and 
several  drawbacks. 

(5)  The  trans-zygomatic  operations,  by  which 
the  fossa  is  reached  from  the  outer  side.  On  no 
grounds  can  these  be  recommended. 

It  will  be  seen  that  the  choice  of  the  surgeon 
lies  between  the  first  and  second  of  the  above 
methods,  and  I  believe  the  first  to  be  the  better. 

III.  Intracranial  Resection   of  the  Main   Division 
of  the  Fifth  Nerve. 

Two  main  considerations  naturally  suggest  them- 
selves in  cases  of  very  severe  and  persistent 
neuralgia,  which  is  confined  to  the  distribution  of 
one  of  the  three  main  divisions  of  the  fifth  nerve. 

(i)  It  is  logical  to  confine  operative  interference 
to  the  division  which  is  alone  implicated. 

(2)  The  nearer  to  the  Gasserian  ganglion  that  the 
resection  can  be  performed  the  less  will  be  the  risk 
of  recurrence. 

It  is  further  important  to  note  that,  even  when 
slighter  radiations  of  pain  have  accompanied  intense 
neuralgia  of  one  division,  operation  on  the  latter 
alone  will  secure  cessation  of  the  pain  in  the 
other.  This  rule  is  probably  not  absolute,  but  Prof. 
Chiene  of  Edinburgh  tells  me  that  he  has  noticed 
this  result  in  several  cases.  All  three  divisions  of 
the    fifth    nerve    can    be    completely   isolated    only 


68 

inside  the  skull.  The  superior  maxillary  trunk 
in  whose  distribution  persistent  neuralgia  is  fairly 
common,  has  an  intracranial  course  of  about  half 
an  inch.  This  portion  can  be  completely  isolated 
and  removed,  so  that  there  is  no  possibility  of  new 
nerves  growing  between  the  ganglion  and  the 
peripheral  branches. 

In  one  case  of  my  own,  given  in  detail  (on 
page  70),  the  intracranial  resection  of  this  nerve 
was  perfectly  successful.  The  two  earliest  opera- 
tions of  Prof.  Krause  for  fifth  nerve  neuralgia 
concerned  the  superior  maxillary  trunk  alone. 
Subsequently  he  performed  the  major  operation 
(removal  of  the  entire  ganglion),  and  holds 
that  this,  with  division  of  the  root  of  the 
ganglion,  "  alone  protects  the  patient  from  recur- 
rence." This  is  too  absolute  a  statement,  I  think, 
from  Prof.  Krause's  account,  that  it  is  certain  in 
some  of  his  cases,  the  ophthalmic  division  with  its 
root  fibres  escaped.  Certainly,  in  many  cases  in 
which  these  have  been  deliberately  spared,  no  re- 
currence of  the  neuralgia  has  taken  place  after 
intervals  of  three  to  five  years,  as  in  the  case  of 
several  of  my  own  patients. 

Dr.  J.  Crawford  Renton,^  in  two  cases,  deliberately 
avoided  interfering  with  the  ophthalmic  division, 
and  in  both  the  neuralgia  was  entirely  cured. 
G.    R.    Fowler,^  in  a  case   in   which   the   neuralgia 

^  British  Medical  Journal,  November,  1900. 

^  Fowler,  New  York  Medical  Record,  1894,  P-  745* 


eg 

was  confined  to  the  second  and  third  divisions, 
commenced  an  operation  by  the  temporal  route, 
intending  to  excise  the  whole  Gasserian  ganglion. 
He  had  previously  ligatured  the  external  carotid 
artery,  and  the  haemorrhage  was  but  slight  ;  never- 
theless, he  found  it  impossible  to  remove  the 
ganglion,  owing  to  its  close  adhesion  to  the  dura 
mater.  He  divided  completely  and  removed  parts 
of  the  superior  and  inferior  maxillary  divisions. 
The  patient,  who  had  been  previously  addicted  to 
large  doses  of  morphia,  entirely  left  off  the  drug. 
At  the  end  of  two  years,  when  he  was  last  seen,  no 
recurrence  of  pain  had  taken  place,  and  there  was 
complete  anaesthesia  in  the  area  supplied  by  the 
two  divided  nerves. 

In  seven  cases  of  my  own,  in  which  the  excision 
was  deliberately  limited  to  the  lower  part  of  the 
ganglion  with  the  two  lower  divisions,  the  patients 
have  been  entirely  free  from  recurrence  of  pain. 
They  have  been  followed  up  for  periods,  ranging 
from  two  to  seven  years. 

(i)  So  far  as  I  can  ascertain  the  ophthalmic 
trii7ik  alone  has  never  yet  been  the  subject  of  intra- 
cranial excision. 

(2)  The  second  or  superior  maxillary  division 
is  the  most  suitable  for  intracranial  resection,  as 
nearly  half  an  inch  of  it  is  available  before  it 
passes  through  the  foramen  rotundum. 

The  method  of  operating  will  be  understood  by 
reference  to  fig.  8,  and  from  the  description  of 
the  following  case  : — 


70 

A  ship's  officer,  aged  nearly  60,  but  of  fine  con- 
stitution, had  suffered  for  several  years  from  intense 
pain  in  the  right  cheek  and  upper  jaw.  The 
neuralgia  was  typically  epileptiform,  the  attacks 
becoming  more  and  more  frequent  during  the  last 
four  years.  He  had  had  a  number  of  teeth 
removed  without  the  slightest  relief,  and  medi- 
cines were  equally  unavailing.  He  struggled  on 
with  his  duties  on  board  a  Cape  liner,  and  about 
Christmas,  1902,  he  consulted  Sir  Frederick 
Treves  with  regard  to  operative  measures,  who 
kindly  sent  him  to  me  with  a  note  suggesting 
removal  of  Meckel's  ganglion  and  the  infra-orbital 
nerve.  The  distribution  of  the  neuralgia  was 
always  the  same,  and  the  parts  were  very  tender, 
though  during  an  attack  some  relief  was  obtained 
by  the  patient  violently  grasping  the  tissues  of  the 
cheek.  The  lower  eyelid,  both  sides  of  the  cheek, 
the  palate  and  the  gums  on  the  right  side  formed 
the  area  involved.  Lachrymation  and  congestion 
of  the  right  eye  were  frequent. 

It  might  be  suggested  that  exposure  on  deck 
to  wind  and  wet  was  a  predisposing  cause  of  the 
neuralgia,  but  the  attacks  were  equally  severe 
when  he  was  on  land,  and  they  occurred  both  by 
day  and  night.  He  had  the  aspect  of  great  suffer- 
ing and  depression. 

My  friend  Mr.  T.  Crisp  English  assisted  me 
at  the  operation,  which  was  performed  with  the 
patient  fixed  in  a  dentist's  chair,  in  order  to  lessen 


O.D. 


Fig.  8. 

Intracranial  resection  of  the  superior  maxillary  nerve.  A.  B. — Portion  of 
the  nerve  to  be  excised.  CD. — Wall  of  temporal  fossa  cut  away  in  the 
operation.     O.D. — Ophthalmic  division.      G. — Gasserian  ganglion. 


71 

the  trouble  from  venous  haemorrhage.  A  horse- 
shoe flap  was  turned  down  from  the  temporal 
region,  having  its  base  at  the  zygoma,  the  flap 
including  part  of  the  temporal  muscle  and  the 
pericranium.  With  a  large  trephine  and  cutting 
forceps  the  subjacent  bone  was  removed,  and  the 
dura  mater  exposed.  As  in  the  operation  for 
removal  of  the  Gasserian  ganglion,  the  dura  mater 
and  temporo-sphenoidal  lobe  were  then  carefully- 
pushed  upwards  and  inwards,  making  for  the 
foramen  rotundum  as  the  first  landmark.  In  this 
respect  the  two  operations  differ,  as  in  dealing 
with  the  Gasserian  ganglion  the  foramina  spinosum 
and  ovale  are  first  sought  for.  Considerable  diffi- 
culty was  met  with  owing  to  the  thin  and  fragile 
character  of  the  dura  mater,  and  some  cerebro- 
spinal fluid  escaped.  Ultimately,  the  trunk  of  the. 
superior  maxillary  division  and  part  of  the  Gas- 
serian ganglion  were  thoroughly  exposed,  a  broad 
spatula  of  soft  metal  being  used  to  retract  the 
dura  mater  and  brain.  The  whole  of  the  nerve 
was  then  removed,  a  small  drain  being  subsequently 
inserted,  and  the  flap  sutured  in  position.  None 
of  the  bone  removed  was  replaced.  Primary  heal- 
ing followed,  and  no  complication  of  any  sort 
occurred. 

The  patient  returned  a  month  later  to  his  duties, 
and  has  made  regular  voyages  to  and  from  the 
Cape  ever  since.  I  have  waited  eighteen  months 
before    reporting    the    case    in    order   to    ascertain 


72 

that  the  reHef  is  permanent,  and  am  glad  to  state 
that  he  has  not  had  the  shghtest  recurrence. 
The  anaesthesia  is  most  marked  over  the  right 
cheek  and  superior  maxillary  bone,  and  it  also 
involves  the  soft  palate  and  lower  eyelid.  He  can 
eat  and  talk  with  perfect  comfort,  whereas  before 
the  operation  both  acts  brought  on  spasmodic  pain. 
The  scar  is  hardly  to  be  noticed,  the  gap  in  the 
bone  has  practically  filled  up,  and  there  is,  of 
course,  no  paralysis  of  masticatory  muscles  on  that 
side,  such  as  follows  removal  of  the  Gasserian 
ganglion.  I  am  confident  that  no  recurrence  is 
likely  to  take  place. 

It  would  be  erroneous  to  suppose  that  the  opera- 
tion is  an  easy  one  :  the  depth  of  the  nerve  trunk 
(three  centimetres  or  more  from  the  wall  of  the 
temporal  fossa)  and  the  troublesome  oozing  in  a 
narrow  space,  where  it  is  essential  to  see.  and 
define  a  nerve-trunk  of  small  size,  prevent  this. 
But  having  had  the  opportunity  of  assisting  my 
colleague,  Sir  Frederick  Treves,  in  several  opera- 
tions on  Meckel's  ganglion  I  can  safely  assert  that 
the  intracranial  route  is  at  least  as  easy  as  the 
facial  one,  and  I  believe  it  affords  the  more  certain 
access. 

Mr.  Stanley  Boyd  performed  a  similar  operation 
about  the  same  time  as  myself.  In  his  case  the 
result  was  perfectly  satisfactory  for  a  year,  but  at 
the  end  of  that  time  a  slight  recurrence  of  neu- 
ralgia was  reported,  though  its  exact  localisation 
was  doubtful. 


73 

(3)  Of  intra-cranial  resection  of  the  third  or 
inferior  maxillary  division  I  have  had  no  personal 
experience.  The  Gasserian  ganglion  reaches  almost 
to  the  foramen  ovale,  immediately  beneath  which  the 
trunk  breaks  up  into  a  number  of  branches  ;  hence, 
intra-cranial  resection  will  include  the  adjacent 
part  of  the  ganglion  itself,  a  fact  illustrated  by  the 
following  two  cases  : — 

Codivilla,  an  Italian  surgeon,  in  1897,  operated 
on  a  woman  aged  53,  who  had  suffered  for  four 
years  from  severe  neuralgia  in  the  distribution  of 
the  inferior,  maxillary  nerve  alone.  By  the  tem- 
poral route  he  exposed  the  foramen  ovale,  divided 
the  nerve  completely  across,  and  removed  it  with 
the  adjacent  portion  of  the  Gasserian  ganglion. 
The  neuralgia  entirely  ceased,  the  case  being 
reported  in  1898,  one  year  later;  there  was  of 
course  atrophy  of  the  masticatory  muscles  on  that 
side,  with  anaesthesia  of  the  lower  lip  and  part  of 
the  cheek,  and  the  mucous  membrane  over  the  jaw. 
In  another  case,  a  man,  aged  43,  who  had  already 
undergone  an  intracranial  operation  on  the  second 
division,  Codivilla  carried  out  the  same  proceeding 
as  mentioned  above,  on  the  third  division  and  the 
adjacent  part  of  the  Gasserian  ganglion.  The 
operation  had  to  be  done  in  two  stages  (with  three 
days'  interval  between  them),  owing  to  haemorrhage 
from  the  middle  meningeal  artery. 

Conchisions. — From  the  foregoing  account,  it  will 
be  understood  that,  in  the  treatment  of  epileptiform 


74 

neuralgia,  a  certain  proportion  of  cases  may  fairly  be 
subjected  to  less  radical  measures  than  removal  of 
the  Gasserian  ganglion.  In  these  cases  the  neu- 
ralgia is  practically  confined  to  one  main  division  of 
the  fifth  nerve  or  even  to  a  single  branch.  Supra- 
orbital neuralgia  has  not  been  specially  discussed, 
but  now  and  then  a  case  may  arise  in  which  resec- 
tion of  this  nerve  is  justified.  The  operation  is  so 
simple  that  it  does  not  need  description. 

If  the  neuralgia  be  limited  to  the  infra- orbital 
branches^  resection  of  the  nerve  by  following  back 
the  canal  in  the  orbital  floor  may  be  tried.  If  the 
neuralgia  concern  also  the  palatine  branches^  intra- 
cranial resection  of  the  superior  maxillary  trunk 
should  be  carried  out.  If  the  inferior  dental  nerve 
be  alone  affected,  it  should  be  resected  through  a 
trephine  aperture  in  the  outer  table  of  the  lower 
jaw.  When  the  neuralgia  concerns  several  branches 
of  the  inferior  Tnaxillary  division  (e.g.,  the  inferior 
dental  and  the  auriculo-temporal),  intracranial  re- 
section of  the  trunk  and  adjacent  part  of  the  Gas- 
serian ganglion  is  indicated. 

For  all  other  cases,  those  in  which  the  neuralgia 
has  already  invaded  two  of  the  main  divisions  of 
the  fifth  nerve,  the  major  operation  on  the  ganglion 
(see  Chapter  V.)  should  be  carried  out  as  affording 
the  only  hope  of  perinanent  cure. 

If  these  rules  be  followed  the  subject  is  rendered 
simple,  a  host  of  elaborate  operations  may  be  dis- 
carded, and  the  disappointing  results  which  have 
followed  them  in  the  past  may  be  avoided. 


CHAPTER  V. 

Operations  on  the  Gasserian  Ganglion. 

The  surgeon  who  first  suggested  in  print  the 
operation  of  removal  of  the  Gasserian  ganghon 
was  Dr.  Ewing  Mears  of  Philadelphia.  In  the 
Transactions  of  the  American  Surgical  Associa- 
tion for  1884,  he  reported  a  case  of  neurectomy 
of  the  inferior  dental  nerve,  and  at  the  end  of 
the  paper  wrote :  "If  in  any  case  I  believed 
,  .  .  that  the  morbid  condition  had  invaded 
the  Gasserian  ganglion,  I  would  not  hesitate  to 
enlarge  anteriorly  the  oval  foramen,  .  .  .  and 
by  traction  draw  down  the  ganglion  .  .  .  and 
proceed  in  a  cautious  manner  to  break  it  up 
or  remove  it  by  section  with  small  blunt-pointed 
scissors." 

It  is  plain  that  the  operation  proposed,  which 
Dr.  Mears  had  no  opportunity  of  carrying  out 
himself,  was  identical  with  Professor  Wm.  Rose's 
pterygoid  method  which  was  first  carried  out  in 
April,  1890,  the  case  being  published  in  the  Lancet, 
November  i,  1890.  This  was  the  pioneer  opera- 
tion, and  was  followed  next  year,  1891,  by  Sir 
Victor    Horsley's    case    of    division    of    the    roots 


76 

above  the  ganglion.  This  latter  case  proved  fatal 
from  shock,  and  it  is  only  during  the  last  year, 
1 903- 1 904,  that  this  dangerous  method  has  been 
revived  by  other  surgeons. 

In  1892  Dr.  Frank  Hartley,^  of  New  York, 
and  Professor  Krause,^  of  Altona,  independently 
devised  the  temporal  method  of  reaching  the 
ganglion,  and  it  is  only  from  this  date,  i.e.,  twelve 
years  ago,  that  one  can  seriously  estimate  the 
value  of  the  intracranial  operation  for  trigeminal 
neuralgia.  In  1903,  Professor  Krause  was  able  to 
report  that  he  had  followed  one  of  his  earliest 
cases  for  nine  and  a  half  years,  and  that  no  recur- 
rence had  taken  place.  I  have  followed  up  two 
of  my  own  cases  with  the  same  satisfactory  result 
for  seven,  and  seven  and  a  half  years  respectively. 
Krause  claims  for  his  "  first  effective  extirpation  of 
the  ganglion  performed  on  January  31,  1893,  that 
it  was,  undoubtedly,  the  first  operation  of  the  kind." 

Professor  Krause,  in  1901,  stated  that  he  was 
convinced,  after  trial  of  the  various  modifications, 
his  original  method  gave  the  best  exposure  of  the 
ganglion.  With  this  conclusion  I  am  heartily  in 
accord.  The  temporal  route  alone  affords  free 
access,  and  whilst  it  is  necessary  to  remove  the 
bony  floor  of  the  fossa  as  far  inwards  as  the  infra- 


^  Hartley,  New  York  Med.  Journal,  vol.  Iv.,  1892,  No.  12. 
^  Krause,  Deutsche  Med.  Woch.,  1893,  ^o-  i5>  ^^'^  ^  separate 
work,  Die  Neuvalgie  des  Trigeminus,  Leipzig,  i8g6. 


71 

temporal  crest,  there  is  no  need  to  go  further,  as 
some  surofeons  recommend. 

"After  ligature  and  section  of  the  middle  menin- 
geal artery,  the  second  and  third  divisions  of  the 
fifth  nerve  are  fully  exposed  by  lifting  up  the  de- 
tached dura  mater,  the  third  division  is  grasped  and 
stretched  by  narrow  curved  forceps,  whilst  the 
dura  is  pushed  gently  off  the  ganglion  itself  until 
its  roots  are  exposed;  during  this  stage  the  cerebro- 
spinal cavity  is  usually  opened  and  the  fluid  escapes. 
The  ganglion  is  then  seized  with  Thiersch's  forceps 
and  drawn  out,  after  section  with  a  tenotome  of 
the  roots  and  the  second  and  third  divisions." 
Nothing  is  said  as  to  section  of  the  ophthalmic 
or  first  division,  but  this  should  be  cut  rather  than 
torn  through. 

Such  is  an  outline  of  Professor  Krause's  method, 
which  is  almost  identical  with  Hartley's  operation, 
and  it  has  served  as  a  model  for  the  many  surgeons 
who  have  followed  them,  many  of  whom  have 
introduced  more  or  less  important  modifications. 
I  will  describe  in  detail  the  method  now  recom- 
mended, with  the  understanding  that  the  operation 
ofiven  is  that  suitable  for  those  cases  in  which  the 
ophthalmic  division  is  but  little  involved  in  the 
neuralgia,  i.e.,  the  great  majority  which  come 
under  surgical  treatment. 

(i)  Preparation  of  the  Patient. — The  whole  head 
should  be  shaved  and  cleansed  thoroughly,  the  scalp 
being  treated  with  ether  and    i    in   20   solution  of 


78 

carbolic  acid  in  alcohol.  It  is  important  for  the 
patient  to  avoid  long  fasting  before  the  operation, 
and  a  cup  of  good  beef-tea  may  be  taken  three 
hours  beforehand.  The  best  anaesthetic  is  prob- 
ably the  A.C.E.  mixture,  or  one  of  chloroform 
and  ether  without  the  alcohol. 

(2)   The  Instruments,  &c.,  required. — A  dentist's 
chair  with  suitable  head-rest  is    strongly  advised, 


Fig.  9. — Two  forms  of  Hoffmann's  Rongeur  or  cutting  forceps  for  enlarging 
the  aperture  in  the  cranium.     (Half-size.) 

though  some  surgeons  use  the  ordinary  operating- 
table.  In  this  case,  the  shoulders  and  head  should 
be  raised  as  much  as  possible. 

A  good- sized  trephine  is  required  with  a  diameter 
of  i^  inches ;  electric  head-lamp ;  a  broad  and 
blunt-ended  dissector  (fig.  10) ;  Hoffmann's  bone- 
cutting  forceps  for  enlarging  the  trephine  hole 
(fig.  9) ;    a  flexible,  broad,   metal  retractor  for  lift- 


79 


Fig  10.— Aneurism  needle  with  fine  end,  and  two  elevators  for  detaching 
the  dura  mater  from  the  skull.     (Full  size.) 


Fig.  II. — Fine-toothed  forceps  and  flexible  metal  retractor  (Krause's  form). 
(Both  half  natural  size.) 


8o 

ing  the  dura  mater  and  brain  (fig.  ii)  ;  an  aneurism 
needle,  rather  smaller  and  more  curved  than  the 
usual  pattern  (fig.  lo)  ;  fine-toothed  forceps  (fig. 
lo) ;  a  narrow  knife,  such  as  a  tenotome  or  cata- 
ract knife,  which  is  best  made  with  a  blunt  end. 

Small  sponge-holding  forceps  are  used  with  soft 
Turkey  sponge.  The  other  instruments  are  such  as 
are  required  for  every  surgical  operation. 

The  retractor  is  one  of  the  most  important 
instruments  used  in  the  operation,  its  special 
feature  being  that  the  blade  must  be  flexible.  The 
handle  should  be  stiff,  broad,  and  fairly  short,  so 
that  the  assistant  can  keep  a  steady  grip  of  it. 
The  angle  required  between  blade  and  handle 
varies  at  different  stages  of  the  operation,  and  a 
stiff  blade  will  be  liable  to  cause  injurious  pres- 
sure on  the  brain ;  hence,  flexibility  is  essential. 
Krause's  special  retractor  is  figured  on  p.  79.  '  Dr. 
C.  H.  Frazier  has  devised  another,  which  differs 
only  in  the  blade,  which  is  narrower  ;  it  is  figured 
in  "Annals  of  Surgery,"  1903,  p.  462. 

(3)  An  oval  flap  is  shaped,  having  its  base  at 
the  zygoma,  its  upper  end  i|-  inches  above  this 
level,  and  its  posterior  border  running  towards  the 
condyle  of  the  lower  jaw.  The  whole  of  the  flap 
may  well  be  made  inside  the  hairy  scalp,  as  the 
scar  will  be  then  hidden  by  the  growth  of  the 
hair  (fig.    13,  page  81,  right  hand  figure). 

The  scalpel  should  cut  right  down  to  the  bone, 
and   the   flap   (including  the    temporal   muscle  and 


Fig.  12. 

The  bony  floor  of  the  temporal  fossa.     A. — (Shaded  area)  represents  the  part  cut 
away  in  the  Hartley-Krause  operation.     Z. — The  zygoma. 


8i 

the  pericranium)  is  at  once  reflected  by  means  of 
an  elevator.  The  severed  branches  of  the  tem- 
poral artery  are  secured  with  Wells'  forceps. 

The  pin  of  the  trephine  is  now  inserted  midway 
between  the  external  auditory  meatus  (its  upper 
border)  and  the  external  angular  process  of  the 
frontal  bone,  and,  with  every  precaution,  the  disc 
of    bone    is    cut    and    removed.      It    is    of    great 


Fig  13. — Outline  of  horseshoe  flap  shown  in  right  hand  figure.     On  the  left 
hand  figure  the  facial  incision  for  Rose's  pterygoid  operation  is  shown. 

importance  not  to  damage  the  dura  mater  or  the 
anterior  branch  of  the  meningeal  artery,  and  no 
instrument  can  surpass  the  ordinary  trephine, 
guided  by  the  surgeon's  hand.  The  skull  here  is 
thin,  but  fairly  uniform  ;  the  part  removed  is  from 
the  squamous  portion  of  the  temporal  bone.  With 
a  blunt  elevator  the  dura  is  now  carefully  detached 
inwards  all  round  the  aperture,  but  especially  at 
its  lower  margin. 
6 


82 

Hoffmann's  forceps  are  used  to  enlarge  the  open- 
ing as  far  inwards  as  the  infra-temporal  crest.  It  is 
important  to  reach  this  line,  but  unnecessary  to  go 
further  inwards  in  cutting  away  the  bone  (fig.  12). 

The  next  step  is  to  make  for  the  foramen 
ovale    by  continual   detachment   of  the   dura  from 


■F.R. 


r.o. 


F.S. 


-r.R. 


■F.O. 
-F.S. 


-F.R. 


Fig.  14. — The  relative  positions  of  the  three  openings  in  the  base  of  the 
skull  in  different  subjects.  F.R.,  foramen  rotundum ;  F.O.,  foramen  ovale 
F.S.,  foramen  spinosum.  Note  the  variation  with  regard  to  the  antero-pos- 
terior  plane  (dotted  line),  and  the  different  sizes  of  the  apertures.  These  were 
selected  from  the  examination  of  many  adult  skulls  as  representing  the  chief 
variations  that  are  to  be  met  with. 


the  floor  of  the  middle  fossa  and  its  elevation  by 
the  retractor.  An  useful  landmark  for  the  foramen 
is  the  preglenoid  tubercle  on  the  zygoma.  It  is 
probable  that  the  point  of  entrance  of  the  menin- 


83 

geal  artery  (the  foramen  spinosum)  will  be  reached 
first;  it  lies  from  i  to  i'5  millimetres  behind,  and 
a  little  to  the  outer  side  of,  the  inferior  maxillary 
division  (see  F.O.   and  F.S.   in  fig.    14). 

There  is  a  certain  range  of  variation  in  the  size, 
shape,  and  relative  position  of  the  three  foramina, 
a  point  illustrated  by  fig.  14,  in  which  the  open- 
ings are  drawn  exactly  the  natural  size. 

A  variable  amount  of  haemorrhage  will  have 
occurred  during  these  manoeuvres  ;  it  comes  from 
a  number  of  small  veins  and  arteries  and  is  to  be 
controlled  by  pressure  with  small  pieces  of  sponge 
on  holders.  After  the  white  trunk  of  the  inferior 
maxillary  nerve  has  been  exposed,  the  foramen 
rotundum — from  15  to  20  millimetres  in  front  of 
the  foramen  ovale — is  sought  for,  and,  ultimately 
the  whole  superior  maxillary  division  exposed. 
There  must  be  no  undue  haste,  a  few  jninutes'  pause 
whilst  sponge-pressure  is  applied  being  of  much 
use,  and  a  strong  light  must  assist  the  operator's 
work.  Above  all,  it  is  essential  that  the  assistant 
who  uses  the  retractor  must  be  light-handed  ;  the 
less  the  pressure  upon  the  temporo-sphenoidal 
lobe  of  the  brain  the  better. 

Now  comes  the  most  difficult  part  of  the  opera- 
tion, the  exposure  of  the  Gasserian  ganglion, 
which  it  is  useless  to  attempt  until  the  bleeding 
has  practically  stopped.  With  the  "fine  elevator," 
the  thin,  dural  sheath  is  carefully  detached  in  an 
upward  and  backward   direction,  following  the  two 


84 

main  nerve  trunks  (see  fig.  15).  In  some  cases  it 
is  impossible  to  expose  the  ganglion  sufficiently 
without  tying  and  dividing  the  middle  meningeal 
artery.  To  do  this  the  dura  should  be  isolated  all 
round  the  foramen  spinosum,  and  the  aneurism 
needle  (threaded  with  fine  silk),  passed  round  the 
artery.  The  loop  of  ligature  is  then  caught  with  a 
fine-toothed  forceps  and  drawn  towards  the  surface  ; 
a  double  ligature  is  then  applied,  leaving  room  to 
divide  the  artery  between  the  two  knots  ;  slip- 
ping of  the  ligature  is  apt  to  occur  unless  this  is 
carried  out  with  great  care.  Should  this  accident 
happen,  the  foramen  spinosum  should  be  plugged 
with  a  minute  fragment  of  bone  driven  well  in. 

It  will  be  understood  that  the  outer  layer  of  the 
ofanoflion  sheath  is  alone  detached  ;  its  adhesion  is 
always  close,  and  cerebro-spinal  fluid  often  escapes 
from  a  small  puncture.  This  is  of  no  great  im- 
portance. When  the  ganglion  has  been  thoroughly 
exposed,  so  that  the  section  shown  by  the  dotted 
line  in  fig.  15  can  be  made,  and  not  before  this, 
the  superior  and  inferior,  maxillary  divisions  are 
cut  cleanly  across  just  at  the  foramina  ovale  and 
rotundum.  The  best  instrument  for  this  is  a 
narrow  cataract  knife  or  tenotome.  The  ganglion 
being  firmly  held  by  the  toothed  forceps  is  now 
divided  high  up,  as  shown  in  figs.  15,  and  81, 
the  ophthalmic  division  is  left  intact.  The  haemor- 
rhage is  sure  to  increase  at  this  point,  but  all 
difficulty  is  over  and  the  retractor  pressure  should 


C.A 


p;b. 


Fig.  15. 
The  cavernous  sinus  and  Gasserian  ganglion  seen  from  above.  P.B. — The 
petrous  bone.  C. A.— Carotid  artery.  III.,  IV.  and  VI. — The  oculo-motor 
nerves  showing  their  relation  to  the  ophthalmic  division  of  the  fifth  nerve. 
The  relative  position  of  the  middle,  meningeal  artery  and  the  inferior,  maxillary 
nerve  is  shown.  The  dotted  line  crossing  the  Gasserian  ganglion  represents  the 
section  advised  in  removing  the  latter,  together  with  the  superior  and  inferior 
maxillary  trunks.     (From  a  model  in  the  London  Hospital  Museum.) 


85 

at  once  be  left  off.  On  no  account  should  the 
wound  be  forcibly  plugged  with  sponge  or  gauze. 
A  sterilised  solution  of  adrenalin  may  be  of  use, 
the  minute  pieces  of  sponge  being  dipped  in  it. 

Patience  and  a  good  light  are  the  chief  essen- 
tials for  a  proper  section  and  removal  of  the  gan- 
glion ;  the  operator  must  see  exactly  what  he  is 
cutting,  and  must  remember  the  close  proximity  of 
the  cavernous  sinus. 

The  patient's  head  is  now  turned  a  little  on' 
the  side  so  that  blood  can  run  out  easily,  a  small 
spiral  drainage  tube  is  inserted,  and  the  flap  sewn 
in  place  ;  no  bone  is  replaced.  A  large  sterile 
dressing  is  then  secured  firmly  to  the  head  with 
a  muslin  bandage ;  the  tube  should  be  removed 
next  day.  ^ 

After  Treatment. — If  the  patient  has  been, 
addicted  to  morphia  until  just  before  the  opera- 
tion, it  is  sometimes  advisable  to  give  a  hypo- 
dermic injection  on  the  night  following  it.  If 
there  is  evidence  of  marked  shock,  strychnia  should 
be  injected.  In  several  of  my  cases  shock  has 
been  conspicuously  absent,  the  patient  being  able 
to  sit  up  in  bed  on  the  day  following  the  opera- 
tion. The  wound  has,  in  every  case,  healed  by 
first  intention.  Suppuration  is,  of  course,  a  most 
dangerous  complication,  and  hence  the  most  sedu- 
lous care  should  be  taken  in  previous  disinfection 
of  the  scalp,  and  in  all  aseptic  details  of  the 
operation. 


86 

Sir  Victor  Horsley^  notes  that  bleeding  from 
the  meningeal  artery  can  be  "easily  controlled  by 
simply  tipping  in  the  lower  end  of  the  retractor 
so  as  to  kink  the  artery  as  it  leaves  the  foramen 
spinosum," 

He  advocates  tearing  the  roots  from  the  pons, 
a  procedure  which  of  course  always  paralyses  the 
ophthalmic  division.  Many  other  surgeons  carry 
out  this  complete  removal,  which,  for  reasons 
elsewhere  given,  I  deliberately  avoid,  though  in 
exceptional  cases  (where  the  neuralgia  is  severe 
in  the  ophthalmic  distribution)  it  is  certainly 
justified.  Sir  Victor  Horsley's  method  differs  from 
that  given  above  in  the  last  stage  only,  "The 
anterior  and  superior  borders  of  the  ganglion 
having  been  defined  with  a  seeker  and  raised  by 
pulling  up  from  its  bed,  it  is  then  separated  by 
dividing  the  inferior  division,  then  the  middle 
division,  and,  finally,  by  detachment  of  the  superior 
division  of  the  ganglion.  The  ganglion  is  then 
steadily  drawn  upon  until  it  is  found  that  the 
sensory  and  motor  roots  have  become  detached 
from  the  pons,  and  are  extracted  in  its  full  length. 
This  is  followed  usually  by  a  free  flow  of  cerebro- 
spinal fluid,  &c." 

Various  points  in  connection  with  the  operation 
and  its  modifications  require  notice.  The  follow- 
ing are  the  chief  ones  : — 

^  Horsley,  Clinical  Journal,  November  3,  1897. 


87 

I. — Should  the  Operatiojt  be  done  in   One  or   Two 

Stages  ? 

The  long  duration  of  the  operation  has  natu- 
rally led  some  surgeons  to  divide  it  into  two 
stages,  separated  by  a  few  days'  interval.  Severe 
haemorrhage  during  the  exposure  of  the  ganglion 
may  necessitate  this  course,  but  in  Krause's  opinion 
the  operation  should  be  'completed  in  one  stage 
if  possible.  The  risk  of  failure  to  procure  asepsis 
is  thereby  diminished,  and  the  patient  spared  the 
shock  of  two  operations  and  a  double  anaesthetic. 
Codivilla,  in  one  case,  met  with  such  haemorrhage 
from  rupture  of  the  meningeal  artery,  that  he  was 
obliged  to  plug  the  wound,  and  postpone  the  con- 
clusion of  the  operation  for  three  days.  On  the 
second  occasion  the  bleeding  was  again  severe, 
but,  fortunately,  the  operation  was  brought  to  a 
successful  issue.  It  is  not  only  arterial  but  venous 
haemorrhage  that  may  be  so  severe  as  to  compel 
the  operator  to  postpone  the  completion  of  the 
operation.  Of  this,  Mugnai  records  an  example. 
Plugging  the  cavity  with  gauze  or  sponge  appears 
to  be  attended  with  special  risk ;  the  pressure  on 
the  brain  may  cause  aphasia  or  other  paralytic 
symptoms,  and  the  risk  of  sepsis  is  certainly  much 
increased. 

The  answer  to  the  question  proposed  above  there- 
fore is  that  whenever  possible  the  operation  should 
be  completed  at  one  sitting,  but  that  when  excep- 
tional difficulty  arises  from  haemorrhage  in  exposing 


the  ganglion,  it  is  wise  to  defer  its  completion  for 
a  few  days. 

II. —  The  Section  of  the  Skull. 

With  regard  to  the  exact  amount  of  bone  divided 
or  removed,  a  great  deal  of  misplaced  ingenuity 
has  been  expended,  and  the  long  descriptions  by 
various  surgeons  of  "  their  own  methods  of  ope- 
rating "  only  cause  annoying  and  useless  confusion 
in  the  reader's  mind.  For  example,  "  Sapersko's 
method "  includes  ligature  of  the  common  carotid 
artery  (with  grave  risk  of  hemiplegia),  and  division 
of  each  end  of  the  zygoma  (with  the  chance  of 
necrosis — and,  in  any  case,  unnecessary).  "Doyen's 
operation "  included  an  extravagant  skin  incision, 
which  passed  for  some  inches  onto  the  face  ;  divi- 
sion of  the  zygoma  and  coronoid  process  ;  removal 
of  the  skull  wall  as  far  inwards  as  the  foramen 
ovale — in  fact,  an  increase  in  the  severity  of  the 
operation  which  had  no  compensating  feature.  Of 
Doyen's  three  cases  reported,  two  were  fatal  as  a 
direct  result  of  the  operation — a  sufficient  condem- 
nation in  itself. 

It  is  unnecessary  to  describe  the  so  -  called 
"  Quenu's  operation,"  and  the  height  of  absurdity 
is  reached  by  such  terms  as  the  "  Doyen-Quenu- 
Sebileau-Poirier  method,"  which  is  gravely  referred 
to  by  another  French  writer  on  the  subject.  There 
is  a  sad  lack  of  humour  in  some  surgical  authors. 

Division   of  the  zygoma  has  been  employed  by 


-  z. 


Fig.   i6. 

Z. — The    zygoma.       F.O. — Foramen    ovale.  F.S. — Foramen    spinosum. 

A. —  (Shaded  area)   represents    the    part   of   bone  cut   away    in    Cushing's    or 
Poiriers'  operation. 


89 

many  surgeons  as  an  aid  to  the  free  removal  of 
bone  from  the  side  of  the  skull  ;  it  must  be  quite 
exceptional  for  this  to  be  necessary.  Dr.  Gush- 
ing,^ of  Baltimore,  advocates  the  following  method, 
which  he  states  he  has  carried  out  successfully  in 
thirteen  cases  : — 

The  usual  horse-shoe  flap,  with  its  base  at  the 
zygoma,  is  turned  down  ;  the  zygoma  is  divided 
at  each  end,  and  also  reflected  with  the  masseter 
muscle.  The  great  wing  of  the  sphenoid  and  the 
temporal  bone  is  then  cleared  as  low  as  the  origin 
of  the  external,  pterygoid  muscle.  A  small  orifice 
is  then  made  in  the  most  prominent  part  of  the 
sphenoid  wing,  the  opening  being  enlarged  with 
the  cutting  forceps  until  it  is  3  centimetres  in 
diameter.  The  dura  mater  being  detached  and 
pushed  upwards,  the  surgeon  works  inwards  and 
backwards  so  as  to  expose  the  foramina  rotundum 
and  ovale.  Gushing  advocates  removal  of  the 
entire  ganglion  with  the  ophthalmic  division.  The 
zygoma  is  subsequently  fixed  in  place  (fig.    16). 

Gushing's  method,  it  will  be  seen,  is  in  some 
respects  a  reversion  to  Rose's  original  operation, 
in  that  the  opening  in  the  skull  is  made  low 
down,  and  the  zygoma  is  divided.  He  claims  for  it 
two  advantages  over  the  Hartley-Krause  method  ; 
first,   a    more    direct    access    to    the    ganglion,   and 


^  Gushing,  Journal  of  Amer.  Med.   Assoc,    April   28,   igoo, 
P-  1035. 


90 

secondly,  the  avoidance  of  the  middle  meningeal 
artery.  As  noted  elsewhere,  the  latter  vessel  may 
be  avoided  also  in  the  usual  temporal  operation. 
The  division  of  the  zygoma  is  a  distinct  drawback, 
and,  in  addition,  the  coronoid  process  of  the  lower 
jaw  comes  in  the  way.  That  Cushing's  slight 
modifications  present  any  real  gain  may  well  be 
doubted,  and  the  complece  removal  of  the  ganglion 
with  its  ophthalmic  division,  which  he  recom- 
mends, is  certainly  unnecessary  in  most  cases,  and 
may  lead  to  the  subsequent  loss  of  the  eye. 

In  all  essentials  what  has  been  described  as 
Cushing's  method  is  identical  with  M.  Poirier's 
procedure,  details  of  which  were  published  three 
years  before,^  i.e.,  in  1897.  There  is  the  same 
oval  flap,  the  same  division  and  downward  dis- 
placement of  zygoma,  section  of  temporal  muscle 
and  detachment  of  external  pterygoid,  exposure  of 
foramen  ovale,  trephining  of  bone  forming  the  roof 
of  the  zygomatic  fossa,  and  removal  of  the  whole 
ganglion.  The  only  possible  difference  that  the 
careful  reader  will  find,  is  that  Poirier  removes 
rather  more  bone,  thus  giving  better  access  to  the 
ganglion.  It  is  at  least  strange  that  Mr,  Gushing 
and  Professor  Kocher  (who  writes  of  the  former's 
modification    as   original,   and    constituting  a  great 


^  Poirier's  method  is  figured  and  described  in  detail  in 
Chipault,  Chiv.  Nerveiise,  vol.  i.,  pp.  394  to  398.  It  was  pub- 
lished before  this  in  the  Tyav.  Neur.  Chiv.  Chip.,  1897,  ii.,  213. 


91 

improvement)  do  not  mention  Poirier's  work.  The 
dispute  as  to  priority  on  such  a  matter  is,  however, 
hardly  worth  raising. 

III. — The  Osteoplastic  Method. 

Many  surgeons  '  have  turned  down  a  quad- 
rangular flap  of  bone  with  the  soft  tissues  instead 
of  trephining.  This  method  necessitates  making 
four  small  apertures  in  the  bone  to  correspond 
with  each  angle  of  the  flap ;  the  sides  may  be 
divided  with  a  chisel,  or  cut  entirely  from  within 
outwards  by  means  of  a  fine  Gigli's  saw.  The 
advantage  of  replacing  the  bone  may  well  be 
questioned.  The  aperture  made  by  trephining  is 
soon  closed  up  largely  or  entirely  by  bone,  so 
that  a  few  months  later  the  intracranial  pulsation 
can  hardly  be  detected.  I  have  never  known  the 
slightest  complaint  made  by  the  patient  with  regard 
to  the  supposed  weak  spot.  On  the  other  hand, 
if  a  large  osteo-plastic  flap  is  made,  more  free 
access  to  the  middle  fossa  is  probably  secured 
than  by  trephining.  This  is  the  sole  advantage 
that  can  be  claimed. 

The  following  points  may  be  urged  against  the 
method  : — 

(i)  In  the  manipulations  carried  out  with  the 
drill  or  small  trephine,  the  chisel,  and  the  saw,  and 
in  the  necessary  detachment  of  the  dura  mater,  the 
latter  is  extremely  apt  to  be  torn  and  bruised. 


92 

(2)  The  middle  meningeal  branches  are  easily- 
damaged^  and  will  give  considerable  trouble  ;  many- 
cases  of  this  could  be  quoted. 

(3)  Even  more  serious  damage  may  be  done  to 
the  brain  ;  thus,  W.  W.  Keen,  in  perforating  the 
skull  with  a  Cryer's  drill,  experienced  free  haemor- 
rhage "  from  a  branch  of  the  middle  cerebral 
artery  "  and  an  extensive  clot  formed.  The  patient 
was  hemiplegic  after  the  operation,  and  died  on 
the  third  day. 

(4)  The  flap  is  decidedly  in  the  way  during  the 
later  stages  of  the  operation. 

(5)  After  all  his  time  and  trouble  spent  in 
turning  down  the  flap  of  bone,  the  operator  may 
decide  that  it  is  unsafe  to  replace  it,  owing  to 
separation  of  the  pericranium,"  or  other  cause. 

(6)  Probably  the  replaced  bone  will  survive,  but 
this  is  not  certain,  and  its  necrosis  is  a  most 
dangerous  complication,  as  septic  meningitis  is 
almost  inevitable. 

For  the  above  reasons  it  appears  best  not  to 
employ  the  osteo-plastic  flap,  though  the  surgeon's 
predilections  must  decide  this.  Should  it  be  used, 
the  greatest  care  should  be  taken  in  detaching  the 
dura  mater  so  as  not  to  tear  the  meningeal  artery, 

^  e.g.,  cases  recorded  by  S.  P.  Weeks,  Trans.  Amer.  Surg. 
Assoc,  1897,  p.  171,  and  W.  W.  Keen,  Amer.  Journal  of  Med. 
Science,  1896,  cxi.,  p.  68. 

^  As  in  a  case  operated  on  by  J.  Raum,  in  1897,  quoted  in 
Chipault's  Chirurgie  Nerveuse,  vol.  ii.,  p.  192. 


93 

and  the  chisel  alone  should  certainly  not  be  used 
for  the  entire  section  of  the  bone.  All  the  electric 
drills  and  cutters  are  unsafe  as  being  difficult  to 
control,  and  apt  to  slip  through  the  dura  mater 
into  the  brain.  Professor  Krause  uses  Doyen's 
perforator  to  make  two  openings  at  the  upper 
angles  of  the  flap  ;  with  Dahlgren's  cutting  forceps 
he  then  completes  the  upper  section  and  also 
divides  the  bone  down  to  the  level  of  the  zygoma. 
A  spatula  being  passed  between  the  bone  and 
dura,  the  former  is  grasped  by  forceps  and  bent 
downwards  so  as  to  fracture  it  transversely,  oppo- 
site the  zygoma.  With  cutting  forceps  the  portion 
of  squamous  bone  and  great  wing  of  the  sphenoid, 
between  the  line  of  fracture  and  the  infra-temporal 
crest,  is  then  excised  bit  by  bit.  Krause  points 
out  that  it  is  essential  to  remove  the  bone  as  far  ' 
inwards  as  the  crest,  but  unnecessary  to  go  further. 
"As  to  resection  of  the  zygoma  it  is  absolutely 
useless."  Chipault,  however,  writing  in  1904,  says 
that,  in  France,  all  operators  on  the  Gasserian 
ganglion  employ  some  method  involving  division 
of  the  zygoma,  and  that  the  simple  temporal  route 
finds  no  advocates  there.  It  is  of  special  interest 
to  note  that  Chipault  speaks  of  the  mortality  of 
operations  on  the  ganglion  as  being  enormous  !  ^ 


^  Chipault,  Etat  Acttiel  de  la  Chir.  Ncrvaise,  1904,  vol.  ii., 
p.  404. 


94 


IV. —  The  Question  of  Ligature  of  the  Meningeal 

Artery. 

It  is  possible  to  remove  the  Gasserian  ganglion 
without  division  of  this  artery  ;  but  undoubtedly 
its  division  between  two  ligatures  allows  of  the 
dura  mater  being  lifted  up  more  completely,  and 
Krause  has  carried  this  out  in  all  his  operations, 
and  recommends  that  it  should  always  be  done. 
There  are  certain  variations  in  the  position,  &c., 
of  the  foramen  spinosum  through  which  the  artery 
enters  the  skull.  Thus  in  three  of  his  twenty- 
five  cases  Krause  found  a  double  foramen,  through 
which  the  two  main  arterial  branches,  anterior  and 
posterior,  passed.  The  usual  position  in  the  adult 
skull  for  the  spinous  foramen  is  2  millimetres 
behind,  and  about  i  millimetre  outside  the  foramen 
ovale  (see  fig.  14,  page  82). 

An  aneurism  needle  with  a  short,  sharp  curve 
is  necessary ;  it  should  be  threaded  with  fine  silk, 
which  is  less  likely  to  slip  than  catgut.  The  dura 
mater  ensheathing  the  vessel  must  be  carefully 
detached  upwards,  so  that  a  space  is  obtained 
between  the  two  ligatures.  With  the  greatest 
care,  however,  one  or  other  ligature  is  apt  to  slip 
off.  In  this  case  Krause  recommends  that  a  rect- 
angular hook  should  be  pressed  down  into  the 
foramen  spinosum.  Horsley's  aseptic  wax  may  be 
used. 

I   have  succeeded   in   dealino-  with   the  o-ang^lion 


95 

satisfactorily,  in  one  or  two  cases,  without  dividing 
the  meningeal  artery,  but  this  certainly  cannot 
always  be  done.  Out  of  twelve  cases  operated  on 
by  Italian  surgeons,  formal  ligature  of  this  vessel 
was  found  to  be  necessary  in  nine. 

V. — Pittgging  the  Foramina  Rotunduin  and  Ovale. 

Dr.  Robert  Abbe  {^Annals  of  Surgery,  1903) 
points  out  that  the  mortality  following  the  opera- 
tions on  the  Gasserian  ganglion  has  been  need- 
lessly high,  owing  to  the  assumed  necessity  for 
removal  of  the  whole  ganglion.  He  urges  that 
there  is  no  need  for  removal  of  the  ophthalmic 
division  in  the  great  majority  of  cases,  and  he 
thinks  that  section  of  the  second  and  third  divi- 
sions, with  the  interposition  of  a  small  piece  of 
sterile  rubber  between  the  dura  mater  and  the 
foramina  rotundum  and  ovale,  will  suffice  to  obtain 
a  cure.  The  object  of  the  insertion  of  the  rubber 
disc,  which  is,  of  course,  left  in  situ,  is  to  prevent 
reunion  between  the  nerves  and  the  ganglion,  and 
from  the  record  of  five  cases  which  he  reports  he 
shows  that  the  pain  did  not  return  during  periods 
of  from  six  months  to  six  years.  He  also  urges 
that  the  method  is  simple,  speedy,  and  safe. 

With  regard  to  Abbe's  contention,  the  writer 
heartily  agrees  in  limiting  the  interference  in  most 
cases  to  the  lower  part  of  the  ganglion,  with  its 
second    and    third    divisions.      By  this    means    the 


96 

mortality  from  shock  will  be  lessened,  as  well  as 
the  danger  of  injuring  the  cavernous  sinus  and 
the  oculo-motor  nerves.  At  the  same  time  Abbe's 
method  differs  only  from  the  ordinary  one,  de- 
scribed in  detail  in  this  work,  by  the  interposition 
of  the  rubber  disc,  and  therefore  no  special  merit 
of  simplicity  or  safeness  can  fairly  be  claimed  for 
it.  The  rubber  disc  is  probably  of  little  or  no 
value,  for  the  following  reason  :  Supposing  that, 
after  complete  section  at  the  ganglion,  physiological 
reunion  were  to  occur,  we  should  of  course  find  that 
the  parts  made  anaesthetic  by  the  operation,  such, 
for  example,  as  the  cheek  and  hard  palate,  would 
regain  sensation.  In  no  single  case  that  the  writer 
has  followed  up,  or  has  found  recorded,  has  this 
result  occurred  ;  hence,  Dr.  Abbe  seems  to  be 
providing  against  an  imaginary  risk.  When  the 
lower  part  of  the  ganglion  and  its  main  branches 
are  cut,  regeneration  no  more  occurs  than  after 
section  of  the  spinal  nerves  in  a  corresponding 
position.  It  is  worth  noting  that  Abbe  considers 
a  vertical  incision  over  the  temporal  fossa  affords, 
with  strong  retraction,  as  good  access  as  does  the 
usual  one  employed,  and  that  he  regards  prelimi- 
nary ligature  of  the  external,  carotid  artery  as  being 
of  advantage  in  controlling-  haemorrhag-e.  He 
believes  that  in  epileptiform  neuralgia  there  is  a 
neuritis  in  front  of  the  ganglion  in  some  parts  of 
the  peripheral  branches  ;  but,  with  regard  to  this 
point,  his  evidence  is  far  from  conclusive. 


I.D. 


Fig.   17. 

The  Gasserian  and  otic  ganglia  viewed  from  the  inner  side  (from  original 
dissection  in  the  London  Hospital  Museum).  The  course  of  the  motor  root  to 
its  complete  union  with  the  inferior  maxillary  division  and  the  main  branches 
of  the  latter  are  shown.  O.N. —Optic  nerve.  S.S. — Sphenoidal  sinus. 
M.B. — Middle  turbinated  bone.  O.G.— Otic  ganglion  showing  its  branches  to 
the  pterygoid  muscles,  the  chorda  tympani,  &c.  I.B. — Inferior  turbinated 
bone.  C.T.N. —  Chorda  tympani  nerve.  I. P. — Internal  pterygoid  plate. 
I.D. — Inferior  dental  nerve  with  mylo  hyoid  branch.  YII. — Facial  nerve. 
A.T.N. — Auiiculo-temporal  nerve.      I. M.— Internal  maxillary  artery. 


97 

Moreover,  simple  section  of  the  main  trunks 
below  the  ganglion,  as  advised  by  Abbe,  is  pro- 
bably less  certain  to  effect  a  cure  than  the  removal 
of  most  of  the  ganglion. 

.  Chipault  has  tried  plugging  the  foramina  rotun- 
dum  and  ovale  with  dentist's  stopping  material, 
with  the  view  of  intimidating  the  fifth  nerve. 

VI. — Division  of  the  Sensory  Root  alone. 

It  is  much  to  be  wished,  in  operating  on  the 
Gasserian  ganglion  for  neuralgia,  that  the  motor 
root,  which  is  in  no  way  concerned,  could  be 
spared.  It  is,  however,  impossible  to  effect  this 
in  Krause's  operation,  so  intimately  blended  with 
the  ganglion  and  the  third  division  is  the  slender 
motor  root  (fig.  17  illustrates  this  well).  Above 
the  aperture  in  the  dura  mater  it  is  possible,  though 
extremely  difficult,  to  isolate  the  sensory  root  and 
to  divide  it  alone.  This  procedure  was  carried 
out,  in  one  case,  with  apparent  success,  by  Spiller 
and  Frazier.  They  dissected  down  to  the  ganglion 
after  the  usual  method,  then  divided  the  dura  mater, 
isolated  the  sensory  root,  and,  hooking  it  outwards, 
cut  it  across.  In  some  respects  their  method  fol- 
lowed that  employed  by  Sir  Victor  Horsley,  in 
his  solitary  case  of  intradural  division  of  the  gan- 
glionic roots  ;  only,  they  spared  the  motor  one. 
The  fatal  result  in  Horsley 's  case  deterred  sub- 
sequent operators,  and  the  uncertainty  of  Spiller 
7 


98 

and    Frazier's    method    will,    we    think,    have    the 
same   effect.      It    is,  however,  probable   that    many 
surgeons  will   attempt    the  division   of  the  sensory 
root    above    the    ganglion,    since    during   the   last 
year  it  has  been  suggested  in  many  quarters  ;  and, 
it   is  to  be  feared  that,  if  this   should  happen,  dis- 
credit   will    be    brought    on    the    whole    subject   of 
operations    on    the   Gasserian  ganglion.     The  sole 
recommendation    is  the  preservation  of  the  motor 
root,     an     extremely     difficult     proceeding    when 
cerebro-spinal    fluid    and    blood  are  harrassing  the 
operator.      It   is  of  interest  that,   in  the  analogous 
operation    of    division    of    the    auditory    nerve    for 
vertigo,  the  facial  trunk  has  more  than  once  been 
cut   also,   though    the   distinction   between   them   is 
easier    to    make    out    than    that    between    the    two 
parts    of    the    fifth    nerve.      Repeated    experiment 
has  convinced  me  that,   in  the  cavum  Meckelii,   it 
is   impossible    to    divide   the   sensory  portion   com- 
pletely   without    sacrificing    the    motor    root    (see 
fig.    1 8)  ;    above  the   cavum  it  is  so   difficult  as  to 
depend    almost    upon    chance.      Professor    Krause, 
after  fruitless  attempts  to  preserve  the  motor  root, 
when    dealing   with    the    Gasserian    ganglion,    has 
quite  given  them  up,  and  remarks  that  the  trouble 
caused    by  one-sided   paralysis    of   the    masticatory 
muscles  is  insigrnificant. 


Fig.  i8. 

The  Gasserian  ganglion,  viewed  from  the  external  and  internal  surface. 
The  motor  root  is  seen  to  lie  on  the  median  aspect  of  the  sensory  one  to  which 
it  closely  adheres,  becoming  completely  incorporated  with  the  front  of  the 
internal  maxillary  division.  The  dotted  line  on  the  left  figure  shows  the 
section  advised  to  spare  the  ophthalmic  division.     (Modified  from  Riidinger.) 


99 


VII. — Ligature  of  the  External  Carotid. 

It  is  natural  to  suppose  that  one  of  the  main 
difficulties  of  the  operation,  namely  hsemorrhage, 
would  be  materially  diminished  by  preliminary 
ligature  of  the  external  carotid  artery  ;  but  so 
free  is  the  collateral  circulation  that  even  the 
arterial  bleeding  seems  to  be  but  little  affected  by 
this  procedure.  I  have  only  once  employed  it, 
but  in  this  case,  the  ligature  being  performed  in 
the  middle  of  the  operation,  no  apparent  effect 
was  produced.  G.  R.  Fowler  tied  the  external 
carotid,  as  a  preliminary  measure,  in  two  cases  ;  in 
one,  "abundant  bleeding  occurred,  as  the  dura 
mater  was  separated  from  the  middle  fossa,"  and 
the  completion  of  the  operation  had  to  be  post- 
poned. Unfortunately,  his  patient  died  from  septic 
infection  following  plugging  with  gauze.  In  the 
second  case  the  bleeding  was  insignificant.  Keep- 
ing the  patient  in  an  upright,  sitting  posture  is  far 
more  effective  than  ligature  of  the  external  carotid, 
since  it  checks  both  venous  and  arterial  bleeding. 

It  is  curious  that  ligature  of  the  common  carotid 
should  have  ever  come  into  vogue  as  a  treatment 
for  intense  neuralgia  of  the  fifth  nerve.  On  no 
physiological  theory  could  the  impairment  of  blood 
supply  be  likely  to  suppress  pain,  especially  if,  as 
Keen  has  urged,  the  blood-vessels  of  the  ganglia 
are  already  narrowed  by  disease.  A  wide  ex- 
perience of  the  operation  has  shown  that,  in  some 


100 

cases,  temporary  relief  is  afforded  ;  in  the  case  of 
one  patient^  the  pain  only  recurred  after  three  or 
four  years'  interv^al,  but  in  the  majority  there  is  not 
even  a  temporary  cure.  Moreover,  the  danger  of 
hemiplegia  following  ligature  of  the  common  carotid 
artery,  especially  in  old  subjects,  is  too  great  to 
justify  its  being  run  without  the  gravest  cause. 
As  a  method  of  treating  epileptiform  neuralgia, 
arterial  ligature  should,  therefore,  never  be  resorted 
to. 

The  same  remark  holds  true  for  excision  of  the 
cervical  sympathetic  ganglia,  which,  by  certain 
writers,  has  been  advocated  as  a  kind  of  surgical 
panacea.  It  could  not  be  expected  to  succeed  in 
cases  of  neuralgia,  and,  experience  has  shown  that 
it  does  not  succeed.  Chipault  is  one  of  the  very 
few  writers  who  has  tried  to  make  out  a  favour- 
able case  for  it"-^  ;  he  had  been  so  impressed  with 
the  "  enormous  mortality "  of  operations  on  the 
Gasserian  ganglion  that,  in  1902,  he  had  only 
performed  three  such  operations  and  preferred  any 
alternative  method. 

VIII. —  The  Pterygoid  Route  from  Below. 

To  Professor  Wm.  Rose  belongs  the  credit  of 
having  first    operated   on    the    Gasserian    ganglion 

^  Dr.  J.  C.  Hutchinson's  case,  briefly  reported  in  Trans,  of 
Am.  Surgeons'  Assoc,  1884,  p.  489. 

■^  Chipault,  Etat  de  la  Chir.  Nerveuse,  1902,  vol.  i.,  p.  443. 


lOI 

from  the  under  surface  of  the  cranial  base.  His 
method,  which  was  followed  by  a  number  of  other 
operators,  is  a  most  elaborate  and  difficult  one. 
Undoubtedly,  in  some  cases,  the  ganglion  was 
reached  and  excised  with  success,  but  the  follow- 
ing objections  have  led  to  its  abandonment  in 
favour  of  the  temporal  route  : — 

(i)  The  division  of  bone  required — the  zygoma 
and  coronoid  process — was  sometimes  followed  by 
necrosis,  non-union,  or  by  stiffness  of  the  jaw,  with 
marked  deformity. 

(2)  The  haemorrhage  was  often  severe  and 
difficult  to  control. 

(3)  The  view  afforded  of  the  ganglion  was 
inferior  to  that  obtained  by  the  temporal  route. 
It  is  certain  that  many  operators  failed  entirely 
to  deal  with  the  ganglion  by  Rose's  method  ; 
hence  recurrence  of  the  neuralgia  was  not  in- 
frequent. 

(4)  The  Eustachian  tube  is  in  special  danger 
of  being  injured  ;  this  may  be  a  serious  com- 
plication. 

Thus  Caponotto,  an  Italian  surgeon,  records  a 
case  in  which  the  operation  was  followed  by  marked 
rise  of  temperature,  and  bleeding  from  nose  and 
mouth.  At  the  autopsy,  five  days  later,  it  was 
found  that  the  Eustachian  tube  had  been  wounded 
and  that  meningitis  had  ensued. 

It  has  been  already  noted  that  Poirier's  or 
Cushing's    operation    is     a     compromise    between 


102 

Rose's  and  the  Hartley-Krause  method,  and  it  is 
curious  that  a  partial  reversion  to  Rose's  operation 
should  be  advocated,  after  it  had  been  abandoned 
by  all  authorities.  Professor  Rose  himself^  ulti- 
mately gave  up  operations  on  the  Gasserian 
ganglion  and  advocated  extensive  resection  of, 
first,  the  superior  maxillary  nerve,  and  secondly 
(after  an  interval  of  a  few  weeks),  of  the  inferior 
maxillary  division.  He  stated  that  it  was  hardly 
ever  necessary  to  touch  the  ophthalmic  division. 
This  conclusion  agrees  exactly  with  the  operation 
advocated  in  this  work  ;  only,  for  two  extracranial 
operations  a  single  intracranial  one  is  substituted, 
which  deals  only  with  the  lower  part  of  the  Gas- 
serian ganglion  and  the  two  main  trunks  issuing 
from  it. 


^  W.  Rose,  The  Practitioner,  i8gg,  p.  255. 


CHAPTER   VI. 

Excision  of  the  Gasserian  Ganglion.     Results 
AND  Complications  of  the  Operation. 

We  have  to  consider  first  the  conditions  which 
result  from  a  successful  removal  of  the  ganglion. 
The  question  of  subsequent  disfigurement  is  one 
to  which  some  importance  may  be  attached,  as 
after  the  old  pterygoid  operation  from  below  the 
face  was  left  extensively  scarred,  and  when  the 
zygoma  was  divided,  it  did  not  always  unite  in 
good  position.  But  when  the  temporal  (Hartley- 
Krause)  operation  has  been  performed  there  -is 
remarkably  little  disfigurement,  the  scar  being 
usually  hidden  entirely  by  the  scalp ;  there  is 
merely  some  flattening  of  the  temporal  region,  due 
to  atrophy  of  the  underlying  muscle. 

The  amount  of  cutaneous  anaesthesia  depends, 
of  course,  upon  whether  the  whole  ganglion  has 
been  removed,  or  its  ophthalmic  division  spared. 
In  the  former  case  the  skin  will  be  anaesthetic 
from  the  chin  to  high  up  on  the  forehead,  and  from 
the  middle  line  to  the  temporal  fossa.  The  greater 
part  of  the  ear  and  the  masseteric  region  will 
always  retain  sensation,  owing  to  their  supply 
from  ascending  nerves  from  the  superficial  cervical 


104 

plexus.     These    points    are    Illustrated    by  fig.    19, 
taken  from  one  of  my  cases. 

If  the   ophthalmic  division  has  been  spared,  the 
forehead,  the  greater  part  of  the   nose,  the  upper 


Fig.  19. — Distribution  of  the  neuralgia  (lower  figure)  and  anaesthesia  left 
after  complete  removal  of  the  Gasserian  ganglion  (upper  figure).  In  this 
case  the  pain  was  greatest  in  the  parts  deeply  shaded  ;  the  letters  A  B  c  D 
mark  points  of  especial  tenderness.  In  the  upper  figure  it  is  seen  that  the 
ear  and  masseteric  regions  retain  sensation. 


eyelid,  and  (most  important  of  all)  the  cornea  and 
conjunctiva  vi^ill  retain  their  sensation.  The  anaes- 
thetic area  is  then  as  shown  in  fig.  20.  It  will 
be  noticed  that  there  is  a  small  prolongation  of 
the   insensitive   area   at    the   front  of  the  external 


105 

auditory  meatus ;    this    is   prolonged    in  the    upper 
and  anterior  wall  of  the  meatus  itself. 

Dr.  Gushing  states  that  this  area  includes  a 
small  portion  of  the  tympanic  membrane.  As 
regards  the  mucous  membrane  of  the  mouth,  &c., 
the  anaesthesia  will  be  complete  on  the  inner  sur- 


FiG.  20. — Area  of  cutaneous  anaesthesia  left  after  excision  of  the  Gasserian 
ganglion  (the  ophthalmic  division  being  untouched).  Taken  from  a  case  six 
months  after  operation. 

face  of  the  lips,  the  gums,  and  hard  and  soft  palate. 
It  is  less  complete  on  the  anterior  two-thirds  of 
the  tongue  (owing  to  the  chorda  tympani  contain- 
ing sensory  fibres),  and  in  the  pharyngeal  vault. 
Sensation  in  the  Eustachian  tube  is  much  im- 
paired, and  the  nasal  cavity  is  insensitive  to  touch, 
though,  of  course,   the  sense  of  smell  is  retained. 

Dr.    Gushing    {Johns    Hopkins    Bidletin,     1904) 
has   made   careful    and   elaborate   investigations  of 


io6 

the  anaesthetic  area  in  cases  of  extirpation  of  the 
Gasserian  ganglion.  As  might  be  expected,  there 
is  a  small  range  of  variation  in  different  subjects, 
but  his  main  results  asrree  with  the  statements 
made  above. 

Does  the  area  of  anaesthesia  decrease?  In 
some  cases,  possibly  in  all,  a  slight  reduction  in 
the  anaesthetic  area  of  skin  and  mucous  membrane 
can  be  proved  after  some  months  or  years  have 
elapsed.  This  is  of  no  great  importance,  as  the 
numbness  is  rarely  complained  of.  The  paralysis 
of  the  masticatory  muscles,  which  must  follow 
complete  division  of  the  inferior  maxillary  trunk, 
might  be  expected  to  cause  far  more  incon- 
venience. The  masseter,  temporal,  and  the  two 
pterygoid  muscles  are,  after  removal  of  the  Gas- 
serian ganglion,  entirely  deprived  of  their  nerve- 
supply,  and  their  subsequent  wasting  can  easily 
be  proved.  It  is  strange  how  little  trouble  is 
caused  thereby,  as  the  muscles  of  the  opposite 
side  amply  suffice  for  mastication.  In  every  case 
the  patient  eats  better  than  before  the  operation, 
since  no  longer  does  the  attempt  at  chewing  the 
food  bring  on  spasms  of  pain.  When  questioned 
on  the  point  the  patients  state  "they  can  now 
eat  anything." 

Is  the  sense  of  taste  impaired  by  the  paralysis 
of  the  so-called  gustatory  nerve  ? 

It  is  certain  that  the  "gustatory"  nerve  has 
nothing    to    do    with    the    sense    of    taste    in    the 


107 

posterior  third  of  the  tongue  (the  region  of  the 
circumvallate  papillae)  the  glosso-pharyngeal  trans- 
mitting it  from  this  part.  With  regard  to  the 
anterior  two-thirds  of  the  tongue,  it  is  generally 
admitted  that  the  taste-organs  are  supplied  by  the 
chorda  tympani  nerve,  which  reaches  the  facial,  and 
undoubtedly  ascends  to  its  geniculate  ganglion. 
After  this  point  the  further  course  of  the  fibres  is 
doubtful,  the  most  probable  being  the  pars  inter- 
media of  Wrisberg,  and  so  to  the  brain.  Dr. 
Harvey  Gushing,  in  an  elaborate  paper,  with 
many  references,^  discusses  the  question,  and 
comes  to  the  following  conclusion :  "  That  the 
perception  of  taste  is  unaffected  on  the  posterior 
portion  of  the  tongue,  and  never  permanently  or 
completely  lost  on  its  anterior  two-thirds  after 
removal  of  the  Gasserian  o^anMion." 

Dr.  Gushing  noted  in  one  or  two  of  his  cases 
that  the  sense  of  taste  was  dulled  for  a  time  m 
the  front  part  of  the  tongue  after  the  operation, 
and  suggested  that  this  was  due  to  "some  inter- 
ference with  chorda  transmission,  brought  about 
by  a  mechanical  or  toxic  disturbance,  due  to 
degeneration  of  the  lingual  or  gastatory  nerve." 
Gushing's  view  is,  however,  directly  opposed  by 
the  evidence  of  several    observers.^     In    one    case 


^  Gushing,    Johns  Hopkins   Hospital  Bulletin,  March,   1903, 
p.  71. 

^  e.g.,  A.  Guinard. 


io8 

in  which  I  had  removed  the  lower  two-thirds  of 
the  gangHon  some  months  previously,  the  patient 
had  certainly  lost  the  power  of  distinguishing 
quinine,  salt,  &:c.,  on  the  anterior  part  of  that 
side  of  the  tongue.  It  was  not  merely  that  the 
sense  of  taste  over  this  region  was  dulled  (in 
Cushing's  words)  :  it  was  entirely  lost.  The  case 
is  detailed  on  p.  50.  Thus,  after  excision  of  the 
Gasserian  ganglion,  permanent  anaesthesia  over  a 
large  area  of  skin  and  mucous  membrane  is  left ; 
the  sense  of  taste  is  impaired  on  the  side  operated 
on  ;  the  masticatory  muscles  waste.  Nevertheless, 
the  patient  experiences  little,  if  any,  discomfort 
from  the  loss  of  sensation  ;  he  is  able  to  take  food 
far  better  than  before,  and  the  disfigurement  (if 
the  temporal  route  has  been  followed)  is  trifling. 
There  is,  however,  one  point  with  regard  to  com- 
plete extirpation  of  the  ganglion  that  deserves 
special  note,  namely,  the  risk  of  subsequent 
keratitis,   and  even  loss  of  the  eye. 

Neuro-pm^alytic  Keratitis. — This  is  a  serious 
drawback  to  the  operation  of  complete  removal  of 
the  ganglion,  the  danger  of  which  is  entirely  avoided 
in  the  modified  method. 

How  frequently  it  occurs  can  hardly  be  estimated 
from  the  cases  recorded,  especially  when  they  have 
been  reported  soon  after  the  operation.  In  the 
only  one  of  my  cases  in  which  the  eye  was 
ultimately  lost,  owing  to  spreading  ulcer  of  the 
cornea,  the  trouble  developed  some  months  after 
the  patient  had  left  the  hospital. 


I09 

The  patient  was  a  man,  aged  64,  who  was  sent  to  me 
by  Dr.  Simpson.  He  had  suffered  for  five  years  from 
severe  epileptiform  neuralgia.  His  paroxysmal  attacks 
started  in  the  lower  jaw,  spreading  to  the  whole  side  of 
the  cheek,  the  lower  part  of  the  forehead,  and  temple  ; 
they  involved  also  the  region  behind  the  ear,  and  in  a 
severe  attack  the  whole  of  the  right  side  of  the  scalp. 
This  radiation  6f  the  pain  to  parts  beyond  the  area 
supplied  by  the  fifth  nerve  has  been  noticed  in  many 
cases,  and  does  not  contra-indicate  excision  of  the  ganglion, 
by  which  operation  it  is  put  an  end  to. 

During  the  attacks  there  was  usually  marked  lachryma- 
tion,  and,  more  than  once  there  had  been  conjunctivitis 
on  the  affected  side.  The  pain  was  not  controlled  even 
by  opium,  and  the  patient's  condition  was  a  very  miserable 
one.  Excision  of  the  Gasserian  ganglion  was  performed 
in  June,  1899,  the  chief  difficulty  met  with  being  due  to 
the  extreme  thinness  of  the  dura  mater.  In  raising  this 
membrane  from  the  middle  fossa  it  was  unavoidably  torn, 
with  the  result  that  the  cerebro-spinal  fluid  escaped. 
Owing  probably  to  this  fact,  the  pressure  of  the  broad 
retractor  exerted  more  deleterious  effect  on  the  brain  than 
usual,  and  he  had  for  some  little  time  after  the  operation 
partial  paralysis  of  the  opposite  arm  and  leg,  which  slowly 
improved.  The  wound  healed  perfectly  and  the  neuralgia 
has  been  completely  cured.  His  anaesthesia  involves  not 
only  the  right  side  of  the  tongue,  palate,  cheek,  nose,  &c., 
but  also  that  half  of  the  forehead,  the  cornea,  and  con- 
junctiva. With  regard  to  the  eye,  all  went  on  well  until 
several  weeks  after  he  had  returned  home.  He  then 
developed  keratitis,  which  slowly  spread  in  spite  of  treat- 
ment, and  ultimately,  as  the  eye  was  useless,  I  excised  it. 

It  is  difficult  or  impossible  to  estimate  the  pro- 
portion of  cases  in  vv^hich  corneal  trouble  has 
followed  the  complete  operation.  Naturally,  surgeons 
do  not  dvv^ell  on  this  complication  when  publishino- 


no 

their  experience.  That  the  risk  is  a  real  one  is 
shown  by  the  following  nine  instances,  which  I  have 
collected  from  various  published  records  : — 

(i)  Biondi.  Central  ulcer  of  cornea  with  hypopyon 
two  months  after  operation.  The  condition  of  the  eye 
improved  after  a  time,  and  apparently  did  not  necessitate 
excision. 

(2)  G.  Andrews  {Internat.  Med.  Mag.,  Philad.,  1892, 
I.,  p.  486),  "  ulcers  of  the  cornea  appeared  after  the  opera- 
tion, when  the  aseptic  compresses,  which  had  been  placed 
over  the  eye,  were  removed."  It  is  probable  that  these 
ulcers  were  not  due  to  complete  corneal  anaesthesia,  since  ' 
the  ganglion  was  supposed  to  have  been  removed  by  the 
curette.  The  ulcers,  moreover,  soon  healed,  whereas  the 
true  neuro-paralytic  ones  are  most  obstinate. 

(3)  W.  W.  Keen  {Ainer.  Journal  of  Med.  Sciences, 
Jan.,  1896).  At  the  end  of  the  operation  the  eyelids 
were  sewn  together ;  four  days  later  they  were  separated, 
and  a  corneal  ulcer  made  its  appearance.  The  subsequent 
history  is  imperfect,  but  it  would  appear  that  the  ulcer 
slowly  improved. 

(4)  W.  W.  Keen  {Ibid.  November,  1898).  The  eye  on 
the  affected  side  "  became  blind." 

(5)  Davis  {Univ.  of  Pennsylvania  Med.  Bull.,  No,  2, 
1904).  Eight  months  after  complete  removal  of  Gasserian 
ganglion  the  anaesthetic  eyeball  had  to  be  excised,  owing 
to  corneal  ulceration. 

(6)  Gerard-Marchant  {Bull,  de  la  Soc.  de  Chir.,  1896, 
xxii.,  p.  585).  A  fortnight  after  the  operation  the  cornea 
began  to  ulcerate,  and  it  remained  permanently  opaque. 

(7)  A.  Depage  {Bull.  Acad,  de  Med.  de  Beige,  1897,  vol. 
2,  p.  687).  "  The  cornea  on  the  operated  side  ulcerated  ; 
there  was  conjunctivitis,  and  the  sight  was  almost  gone." 

(8)  S.  Coelho  {Revue  de  Chir.,  1899,  xix.,  p.  623).  The 
ganglion  was  wholly  removed  by  tearing  through  its  roots. 
The  cornea  became  opaque  but  subsequently  cleared, 
*'  except  for  a  small  opacity." 


Ill 

(9)  Bougie  {Bull,    de   la  Soc.    de   Ckir.y   1901,   p.  403). 
Ulceration  of  the  cornea  followed  with  chemosis. 

From  the  preceding  ten  cases  it  will  be  seen 
that  whilst  the  danger  is  greatest,  as  Krause 
points  out,  during  the  first  few  weeks,  yet  an 
anaesthetic  cornea  can  never  be  really  safe.  Septic 
dust  may  enter  without  being  noticed  and  set  up  a 
chronic  inflammation,  which  is  very  hard  to  check. 
To  this  cause  must  be  ascribed  the  so-called 
trophic  changes  in  the  eye,  and  if  the  ophthalmic 
division  has  been  dealt  with  and  the  cornea  ren- 
dered permanently  anaesthetic,  the  safest  plan  will 
be  for  the  patient  to  wear  protective  glasses  as  a 
continual  precaution.  Sewing  up  the  lids  on  the 
side  concerned  has  been  carried  out  by  some 
surgeons,  but  this  is  an  irksome  measure,  and,  as 
already  pointed  out,  the  temporary  closure  of  the  ' 
lids  affords  no  guarantee  for  the  future. 

Occasionally  the  eye-lesion  takes  the  form  of 
purulent  conjunctivitis,  leading  later  to  ulcerative 
keratitis  —  from  this  Bougie's  patient  was  unfor- 
tunate enough  to  suffer.  In  such  a  case  it  is  pro- 
bable that  the  use  of  too  strong  antiseptic  solutions 
for  bathing  the  eye  is  responsible  for  the  conjunc- 
tivitis— the  surgeon's  precautions  having  been  too 
elaborate.  A  very  mild  antiseptic  lotion  may  prove 
destructive  to  an  anaesthetic  corneal  surface  ;  but  I 
would  again  urge  that  when  the  cornea  has  been 
rendered  completely  anaesthetic  by  removal  of  the 
entire  Gasserian  ganglion  or   section   of   its  roots,^ 


112 


there  will  always  remain  some  risk  of  "  trophic " 
ulceration.  The  fear  of  eventually  losing  the  eye 
is  an  important  drawback  to  such  an  operation,  a 
drawback  which  can  be  entirely  avoided  by  limit- 
ing the  excision  of  the  ganglion  in  the  manner 
described. 

We  will  now  consider  the  direct  mortality  of  the 
operation — the  actual  risk  to  life  which  it  involves. 

Chipault  wrote,  in  1902,  that  the  mortality  of 
these  operations  "is  enormous."  How  far  can 
this  statement  be  justified  ?  Of  Krause's  thirty- 
six  cases  in  which  the  ganglion  was  removed,  six 
died,  i.e.,  16  per  cent.  In  three  of  these,  how- 
ever, the  death  was  due  to  "  influenza,"  or 
pneumonia  (in  one  case  following  heart-failure). 
All  these  three  patients  died  at  the  end  of  the 
third  week  after  the  operation,  and  it  can  fairly 
be  said  that  the  latter  was  only  indirectly  to 
blame,  the  shock  which  resulted,  in  feeble  patients, 
hastening  the  end.  Still,  as  most  of  the  subjects 
are  old,  and  many  of  them  feeble,  it  is  best  fairly 
to  state  Krause's  mortality  as  16  per  cent.  Lexer 
lost  one  case  out  of  twelve,  of  meningitis.  At 
the  post  mortem  of  this  case  a  tumour  of  the  base 
of  the  skull  was  found.      In  a  case   of  my  own  a 

cartilaofinous  tumour  was  found  invading-  the  Gas- 
es o 

serian  ganglion  from  the  adjoining  bone  ;  complete 
removal  was  impossible.  The  patient  recovered 
from  the  operation,  which  was,  in  fact,  mainly 
exploratory.     (See  page  31.) 


113 

It  is  obvious  that  cases,  in  which  the  presence 
of  a  tumour  complicates  the  operation,  should  not 
be  counted  with  the  ordinary  ones.  Lexer's  eleven 
and  my  own  eight  cases  amount  to  nineteen,  with- 
out a  single  death.  Sir  Victor  Horsley,  in  1897, 
had  done  eight  Hartley- Krause  operations  without 
a  death.  He  kindly  tells  me  that,  since  then,  his 
personal  experience  has  increased  to  approximately 
120,  with  six  deaths.^  No  other  surgeon's  statistics 
can,  I  believe,  compare  in  number  and  lowness  of 
mortality  with  Sir  Victor  Horsley's.  Taking  his 
cases  with  Lexer's  and  my  own,  we  have  140  cases 
with  six  deaths,  only  4  per  cent,  and  this  includes 
two  fatal  cases  which  some  surgeons  might  have 
left  out.  The  mortality,  therefore,  so  far  from 
being  "enormous,"  as  Chipault  suggests,  is  very 
slight.  What  has  given  rise  to  the  prevailing  idea 
on  the  subject,  which  it  is  most  important  to  dispel  ? 
The  fact  is  that,  in  the  past,  the  mortality  has  been 
far  too  high,  owing  to  inexperience,  and  still 
more,  to  needlessly  heroic  or  clumsy  methods  of 
operating.  The  collection  of  cases  made  by  Keen, 
Tiffany,  and  others  is  easily  consulted,  and  it, 
undoubtedly,  shows  a  mortality  of  20  per  cent.,  or 
over.     Such  a  heavy  death-rate  is,  fortunately,  quite 

^  Of  the  six  fatal  cases,  cerebral  haemorrhage  was  the  cause 
in  three ;  one  patient  died  from  septic  infection  (from  a  septic 
case  in  the  same  ward  of  the  hospital).  In  the  other  two  cases 
an  interval  of  three  or  four  months  occurred  after  the  opera- 
tion, the  cause  of  death  being  doubtful. 


114 

needless,  but  it  has  deterred  many  physicians  from 
recommending  the  operation  in  suitable  cases. 

The  following  selection  of  fatal  results  has  been 
made,  solely  for  the  purpose  of  illustrating  the 
causes  of  death  and  the  means  of  avoiding  it,  as 
far  as  possible.  It  would  have  been  easy  to 
extend  the  list,  but  for  all  practical  purposes  it  is 
long  enough.  The  reader  will  understand  that 
in  every  one  included  the  temporal  route  was 
adopted  : — 

Fatal  Cases.     Hart  ley -Krause  Method. 

(i)  Bernandi.  Aged  68.  Severe  haemorrhage.  Com- 
plete removal  of  ganglion.  Death  on  fifth  day  from  shock. 
Nothing  found  at  post  mortem  except  slight  ecchymosis 
of  the  temporo-sphenoidal  lobe. 

(2)  Bernandi.  Woman,  aged  61.  Death  from  failure 
of  heart's  action  just  at  the  conclusion  of  the  operation. 
At  the  autopsy  the  heart  was  found  to  be  fatty. 

(3)  G.  R.  Fowler  {Med.  Record  of  New  York',  1894, 
p.  745).  Severe  arterial  and  venous  haemorrhage  during 
the  operation.  All  three  divisions  of  the  nerve  dealt  with. 
Death  four  hours  afterwards.     Patient  aged  45. 

(4)  G.  R.  Fowler.  Patient  aged  50.  Severe  haemor- 
rhage during  the  operation,  although  the  external  carotid 
artery  had  been  tied.  Cavity  plugged  with  gauze.  Death 
from  septic  infection. 

(5)  A.  G.  Gerster  {^Med.  Times,  1895,  P-  5i8)-  Opera- 
tion in  two  stages,  owing  to  haemorrhage.  Gauze  plug 
used.     Death  from  septic  meningitis  and  cerebritis. 

(6)  J.  T.  Finney  {Johns  Hopkins  Hosp.  Bulletin,  1893, 
p.  91).  Patient  aged  69.  Complete  removal  of  the 
ganglion,  "  its  roots  being  torn  from  the  pons  varolii." 
Death  seven  hours  after  the  operation.  The  middle 
meningeal  aperture  had  been  plugged  with  gauze. 


115 

(7)  G.  R.  Fowler  {Medical  Record  of  •New  York,  1894, 
p.  745).  Patient  aged  45.  Very  abundant  haemorrhage, 
arterial  and  venous.  All  three  divisions  were  cut.  Death 
(evidently  from  shock  and  haemorrhage)  four  hours  later. 
This  case  is  specially  noteworthy  on  account  of  the  com- 
paratively early  age  of  the  patient. 

(8)  W.  W.  Keen  {Amer.  Journal  of  Med.  Set., 
January,  1896).  Patient  aged  6t,.  Two  days  after  the 
operation  the  temperature  rose,  and  within  a  week  the 
patient  died  of  septic  meningitis.  The  infection  was 
undoubtedly  due  to  one  of  the  assistants,  who  had  put 
one  of  the  instruments  used  in  his  mouth  before  the 
operation. 

(9)  W.  W.  Keen.  Complete  removal  of  the  ganglion  ; 
the  cavernous  sinus  was  freely  opened  in  dealing  with  the 
ophthalmic  division.  The  haemorrhage  was  arrested  by 
plugging.  The  patient  was  found  to  be  hemiplegic  after 
the  operation  ;  did  not  regain  consciousness,  and  died  on 
the  third  day. 

(10)  Lange  (reported  by  Keen  in  Chipault's  Chirurgie 
Nerveuse).  Patient  aged  63.  The  operation  was  attended 
by  special  difficulty  and  accidents,  the  bone-cutting  forceps 
breaking  and  injuring  the  brain.  The  ganglion  could  not 
be  removed,  and  the  haemorrhage  was  severe.  After  the 
operation,  hemiplegia  was  noticed  on  the  same  side,  death 
resulting  from  cedema  of  the  lungs.  No  explanation  was 
found  post  mortem  for  the  hemiplegia. 

(11)  W.  Meyer,  Patient  aged  30.  Suppuration  in 
connection  with  a  ligature  followed  the  operation,  and 
death  three  months  later  from  cerebral  abscess. 

(12)  W.  P.  Nicholson  (reported  by  Keen,  loc.  cit.). 
Patient  aged  62,  Skull  very  thick;  middle  meningeal 
artery  buried  in  it.  Formidable  haemorrhage  checked  by 
gauze-plugging.     Death  four  days  later.     No  meningitis. 

(13)  J.  Ransohoff  {ibid.).  Patient  aged  50.  Excessive 
haemorrhage.     Death  from  shock. 

(14)  L.  A.  Stimson  {ibid.).  All  three  divisions  dealt 
with.     The  patient's  breathing  stopped  during  the  eleva- 


ii6 

tion  of  the  brain ;  the  pulse  became  very  rapid,  the 
breathing  again  enfeebled,  and  death  ensued  in  six  hours. 
(15)  L.  M.  Tiffany  {Annals  of  Surgery,  March,  1895). 
Patient  aged  71.  Paralysis  of  the  opposite  arm  followed 
the  operation.  The  wound  healed  quickly,  but  had  to  be 
reopened  at  the  end  of  a  week  in  order  to  remove  blood- 
clot.     In  the  third  week  septic  infection  proved  fatal. 

The  main  risks  of  the  operation  are  seen  to  be 
three  :  shock  (sometimes  caused  by  injurious  pres- 
sure on  the  brain),  haemorrhage,  and  septic  infec- 
tion ;  it  may  be  said  these  three  are  one.  Severe 
haemorrhage  is  generally  due  to  opening  the 
cavernous  sinus  during  the  attempt  to  completely 
remove  the  roots  of  the  ganglion  and  its  ophthalmic 
branch  ;  to  check  the  bleeding  the  operator  resorts 
to  plugging  with  gauze,  which  causes  injurious 
pressure  on  the  brain  and  increases  the  risk  of 
septic  infection. 

If  the  patient  be  operated  upon  in  the  vertical 
(sitting)  posture,  as  Krause  recommends,  the  bleed- 
ing is  rarely  severe,  especially  if  the  interference 
is  limited  to  the  lower  two-thirds  of  the  ganglion. 
In  any  case  plugging  with  gauze  should  be  avoided  ; 
a  small  drainage-tube  should  invariably  be  left  in 
the  wound  for  twenty-four  hours,  and,  of  course, 
the  greatest  care  should  be  taken  to  avoid  sepsis. 
It  may  be  noted  that  the  latter  ought  never  to 
occur,  the  temporal  region  being  a  most  favourable 
one  to  render  aseptic,  and  wounds  made  here  heal 
very  kindly.  The  danger  of  causing  injurious 
pressure    by   the  retractor,    during   the    operation. 


117 

should  be  borne  in  mind  throughout  the  operation. 
In  one  of  my  cases  it  was  the  cause  of  temporary 
hemiplegia,  and  several  other  examples  of  it  have 
been  recorded.  Thus,  Krause  records  one  case  in 
which  an  extravasation  of  blood  occurred  into  the 
right  cerebral  hemisphere,  the  patient  ultimately 
recovering.  Biondi  noticed  temporary  aphasia  in 
one  case,  and  in  two  others  slight  auditory  defect, 
due,  doubtless,  to  pressure  on  the  temporo- 
sphenoidal  lobe  during  the  operation,  the  defect 
persisting  for  some  six  months. 

An  instance  of  severe  "  pressure  paralysis " 
following  operation  on  the  Gasserian  ganglion  is 
recorded  by  Dr.  Howard  D.  Collins  [Annals  of 
Surgery,  1903,  vol.  xxxviii.,  p.  665),  The  haemor- 
rhage during  the  operation  was  severe,  and  as  the 
osteo-plastic  flap  method  was  used,  it  is  possible' 
that  an  accumulation  of  blood-clot  may  have  been 
to  blame  for  the  subsequent  paralysis ;  Dr.  Collins, 
however,  attributes  it  solely  to  the  retraction 
employed  during  the  operation.  For  days  after- 
wards the  patient  was  drowsy  and  lethargic ;  there 
was  partial  paralysis  of  both  opposite  arm  and  leg, 
and  complete  paralysis  of  all  the  oculo-motor 
muscles  on  the  same  side.  After  some  weeks  all 
the  paralytic  symptoms  improved  and  ultimately 
cleared  off,  though  the  patient's  memory  was  said 
to  be  permanently  affected. 


ii8 

Oculo-motor  Complications  following  the  Operation. 

These  occur  almost  solely  when  the  whole 
ganglion,  including  the  ophthalmic  division,  has 
been  removed  ;  they  vary  much  in  degree,  and 
may  be  either  temporary  or  permanent.  In  some 
cases  merely  ptosis  or  impaired  movement  of  the 
globe  in  one  or  other  direction  results  ;  in  others 
the  paralysis  may  be  for  a  time  complete.  Of  the 
latter  Mugnai  records  an  example.  At  the  end 
of  three  weeks,  movements  of  the  eye  were  re- 
gained, but  ptosis  persisted.  Other  instances  of 
temporary  paralysis  are  recorded  by  G.  Andrews^ 
(two  cases  out  of  five  operated  on  by  him),  by  F. 
Hartley,^  and  others.  In  a  case  recorded  by  Davis^ 
"  the  third  and  fourth  nerves  were  paralysed  for  a 
time,  and  the  sixth  nerve  was  probably  destroyed." 
As,  however,  the  affected  eye  had  to  be  excised 
later,  owing  to  keratitis,  the  oculo-motor  paralysis 
did  not  matter  very  much.  Lexer  observed  para- 
lysis of  one  or  other  oculo-motor  nerves  in  four  out 
of  twelve  cases  operated  on  by  himself;  in  three, 
the  paralysis  passed  off,  but  in  the  fourth  case  para- 
lysis of  the  sixth  nerve  persisted. 

Professor  Krause  noted  temporary  paralysis  of 
ocular  muscles  in  five  out  of  twenty-five  of  his 
cases. 

^  Andrews,  quoted  by  Keen  in  Chipault's  Chinivgie  Nerveuse, 
vol.  iii.,  p.  691. 

2  Hartley,  Annals  of  Sicvgery,  1893,  I.,  p.  512. 

^  Davis,  Univ.  Pennsylvania  Med.  Bull.,  1904,  No.  2. 


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119 

It  is  obvious  that  this  compHcation  is  a  frequent 
one,  if,  in  the  hands  of  so  experienced  an  operator 
as  Krause,  it  occurs  in  20  per  cent.  ;  but  it  may 
be  avoided  with  almost  complete  certainty,  provided 
that  the  ophthalmic  division  is  spared.  The  close 
relation  of  the  latter  to  the  fourth  and  sixth  nerves 
in  the  wall  of  cavernous  sinus  is  well  shown  in  fig. 
21. 

Laceration  of  the  Dura  Mater. — This  has  often 
occurred  during  the  operation  :  indeed,  during  the 
last  stage,  when  the  thin  covering  of  the  ganglion 
itself  is  being  reflected,  it  can  hardly  be  avoided 
in  many  cases.  The  cerebro-spinal  fluid  escapes 
and,  for  a  time,  may  hinder  the  completion  of  the 
operation,  but,  provided  asepsis  is  secured,  no  other 
harm  will  result.  During  the  early  separation  of 
the  dura  from  the  temporal  fossa,  every  care  should 
be  taken  not  to  perforate  the  membrane,  which, 
however,  varies  greatly  in  toughness  and  degree  of 
adhesion  to  the  bone.  Occasionally,  it  tears  at  the 
slightest  touch,  but  in  other  subjects  it  is  firm  and 
readily  detached. 

Laceration  of  the  Wall  of  the  Cavernous  Sinus. 
— This  happened  in  two  of  Krause's  twenty-five 
cases ;  in  both,  the  severe  haemorrhage  was  ultimately 
stopped  by  compression  (plugging  with  sponge). 
Several  other  instances  have  been  recorded,  and 
it  is  noteworthy  that,  where  plugging  with  gauze 
has  been  necessary,  death  has  resulted  from  slough- 
ing of  dura  mater  or  septic  infection  in  many  cases. 


120 

Wound  of  the  cavernous  sinus  Is  a  most  serious 
complication  for  this  reason,  and  also,  because  it 
renders  the  proper  completion  of  the  operation 
impossible. 

In  concluding  this  review  of  the  various  accidents 
that  may  occur  during  and  after  excision  of  the 
Gasserian  ganglion,  I  may  point  out  that,  provided 
the  modified  form  of  the  operation  be  carried  out, 
(removal  of  the  superior  and  inferior  maxillary 
trunks,  with  the  greater  part  of  the  ganglion,  but 
sparing  the  ophthalmic  division),  the  risks  are 
diminished  in  the  following  respects  : — First,  there 
is  no  anaesthesia  of  the  cornea,  and,  hence,  no 
risk  of  loss  of  the  eye.  Second,  there  should  be  no 
danger  of  injuring  the  oculo-motor  nerves,  nor  of 
wounding  the  cavernous  sinus.  Third,  the  severity 
of  the  operation  is  rendered  less,  the  degree  of 
haemorrhage,  and  the  chance  of  injurious  pressure 
on  the  brain  being  both  materially  diminished. 

Those  who  advocate  the  complete  removal  of  all 
three  divisions  of  the  nerve  with  high  section  of 
the  roots  will,  no  doubt,  reply  that  by  leaving  the 
ophthalmic  trunk  recurrence  of  the  neuralgia  will 
take  place  in  it.  They  may  fairly  be  asked  to 
prove  that  this  has  ever  occurred. 

It  must  be  admitted  that,  in  certain  cases,  opera- 
tion on  the  Gasserian  ganglion,  whatever  form  it 
takes,  is  to  some  extent  a  failure. 

There  is,  of  course,  no  reason  why  neuralgia 
should  not  recur  on  the  opposite  side  of  the  head, 


121 


and  were  arterio-sclerosis  one  of  the  causes  (as 
asserted  by  Keen),  one  would  expect  this  to  occur 
fairly  frequently  ;  but  nothing  is  more  character- 
istic of  epileptiform  neuralgia  than  its  unilateral 
nature,  even  if  it  exists  many  years.  Amongst  the 
records  of  several  hundred  cases,  I  have  been  able 
to  find  only  two  or  three,  in  which  recurrence 
on  the  opposite  side  has  followed  operation.  R. 
Winslow,^  in  1895,  removed  partially  (by  curetting) 
one  Gasserian  ganglion.  The  patient  suffered 
subsequently  from  diplopia,  mental  defect,  and 
aphasia;  all  these  symptoms  cleared  off  In  1896 
she  "  complained  of  neuralgia  on  the  other  side 
of  the  head."  In  no  case  yet  recorded  has  the 
neuralgia  on  the  opposite  side  approached  in 
intensity    the    original    trouble. 

Lexer,  out  of  ten  cases,  observed  recurrence  of 
the  neuralgia  on  the  same  side  in  one,  and  on 
the  opposite  side  of  the  head  in  another  case. 
Salomoni  {Clinica  Ckirurgica,  Feb.  1893),  after 
operation  on  the  Gasserian  ganglion  on  one 
side,  records  that  neuralgia  recurred  on  the  opposite 
one  some  two  months  later.  The  ultimate  result 
is  not  stated. 

I  have  had  the  misfortune  to  encounter  one  of 
these  cases  in  which  recurrence  of  a  certain  kind 
(chiefly  limited  to  the  other  side  of  the  head  and 
face)  has  followed  excision  of  the  Gasserian  ganglion. 

^Maryland  Med.  Journal,  May  2,  1896. 


122 

The  notes  are  as  follows  : — 

Ellen  P.,  a  stout,  and  previously  healthy  woman,  began 
to  suffer  at  the  age  of  37  from  neuralgia  on  the  right  side 
of  the  lower  jaw.  With  the  idea  of  relieving  this,  the 
teeth  were  removed,  whether  decayed  or  not,  from  first 
the  lower,  and  then  the  upper  jaw,  as  far  forwards  as  the 
canine.  No  rehef  whatever  followed  this  procedure.  From 
the  first,  the  pain  was  of  the  spasmodic,  intermittent  type, 
the  intervals  (at  first  a  few  months)  becoming  shorter, 
until,  at  the  end  of  five  years,  she  was  hardly  ever  free 
from  pain.  When  she  came  under  surgical  treatment, 
being  sent  to  me  by  Dr.  F.  M.  Mackenzie,  she  had  endured 
the  neuralgia  for  six  years,  and  her  health  was  much 
lowered  in  consequence.  Medicines  had  but  little  or  no 
effect  in  relieving  her. 

The  pain  was  most  intense  in  three  positions  : — (i)  over 
the  lower  jaw ;  (2)  in  the  cheek,  and  (3)  in  the  temple. 
From  these  areas  the  spasmodic  pain  radiated  upwards 
towards  the  right  eye,  which  constantly  watered,  and 
towards  the  vertex.  In  addition,  the  right  side  of  the 
neck  was  painful,  and  the  whole  right  side  of  the  scalp 
was  so  tender  that  she  could  not  bear  to  comb  her'  hair. 
Mastication  was  accompanied  by  pain,  so  that  she  took 
only  soft  or  fluid  food  with  difficulty.  The  alveolar  surface 
on  the  affected  side  was  extremely  tender,  and  the  act  of 
removing  her  tooth-plate,  or  merely  talking,  invariably 
brought  on  an  acute  spasm. 

It  will  be  noted  that  in  this  case  the  neuralgia  involved, 
primarily,  the  inferior  maxillary  division,  but  had  spread 
to  the  superior  maxillary  one,  whilst  areas  supplied  not 
by  the  fifth  nerve,  but  by  the  cervical  nerves,  were  painful 
and  tender. 

As  in  many  other  examples,  operation  on  the  Gasserian 
ganglion  was  successful  in  removing  the  referred  as  well 
as  the  direct  pain.  Operation  on  February  25,  1903, 
after  preliminary  shaving  of  the  right  side  of  the  scalp 
and  disinfection  of  the  skin.     The  patient  was  throughout 


123 

in  the  upright  position  in  a  dentist's  chair.  No  trouble 
was  met  with  as  regards  haemorrhage  or  exposure  of  the 
gangHon.  The  middle  meningeal  artery  was  left  un- 
divided. The  lower  half  of  the  ganglion  and  both  superior 
and  inferior  maxillary  divisions  were  removed,  the 
ophthalmic  trunk  being  deliberately  spared.  The  bone 
was  not  replaced,  a  small  spiral  drain  being  inserted  for 
twenty-four  hours.     The  wound  healed  by  first  intention. 


Fig.  22. — Anaeathetic  area  left  after  removal  of  lower  part  of  Gasserian 
ganglion.  A,  ophthalmic  nerve  area  (intact).  B,  side  of  nose  (sensation 
retained).  C,  lips  (sensation  largely  lost).  D,  complete  antesthesia.  E, 
sensation  impaired  in  temple.     F,  masseteric  region  (sensation  retained). 

When  she  left  the  hospital  on  March  20th  she  com- 
plained of  headache,  and,  later  on,  the  left  side  of  the  face 
and  head  became  subject  to  stabbing  pain.  She  could, 
however,  sleep  well  (before  the  operation  her  nights  were 
a  misery  to  her)  and  took  food  with  enjoyment.  I  saw 
her  from  time  to  time  and  was  anxious  lest  the  neuralgia 
should  develop  severely  on  the  left  side.  A  second  opera- 
tion and  removal  of  the  other  Gasserian  ganglion  was  not 


124 

to  be  contemplated  without  much  hesitation,  owing  to  the 
complete  paralysis  of  masticating  muscles  that  would 
ensue.  Fortunately,  under  the  administration  of  tonics, 
chiefly  nux  vomica,  with  the  occasional  use  of  phenacetin, 
the  threatening  symptoms  passed  off.  At  the  end  of  ten 
months  from  the  operation  she  was  in  excellent  health, 
and  free  from  pain — was,  in  fact,  "  another  woman."  The 
bony  aperture  has  filled  up  so  that  no  pulsation  can  be 
detected  ;  the  scar  is  well  hidden  by  the  hair,  and  it  is 
almost  impossible  to  detect,  at  first,  on  which  side  the 
operation  was  done.  The  anaesthesia  of  the  face,  which 
gives  her  no  trouble,  corresponds  to  the  distribution  area 
of  the  auriculo-temporal,  the  infra-orbital,  the  buccal,  and 
mental  nerves.  The  distribution  of  the  nasal  branch  of 
the  ophthalmic  is  apparently  more  extensive  than  usual 
in  this  case,  and,  hence,  the  nose  has  retained  sensation. 

Since  the  above  was  written,  she  has  had  some  return  of 
vague  neuralgic  pains  on  the  left  side,  and  the  final  ending 
of  the  case  must  remain  uncertain. 

In  the  case  just  narrated,  the  headache  and  other 
nervous  symptoms  experienced,  after  an  othervi^ise 
successful  operation,  could  not  be  ascribed  to  the 
patient's  leaving  off  morphia,  as  she  had  not  been 
addicted  to  it  previously.  In  another  case  of  my 
own,  in  which  enormous  doses  of  morphia  had 
been  resorted  to  hypodermically,  in  order  to  get 
some  respite  from  the  pain — the  arms  were  scarred 
all  over  from  the  punctures — it  seemed  doubtful 
whether  the  patient  would  be  able  to  discontinue 
the  drug  suddenly  ;  but  not  a  single  dose  was  given 
after  the  operation,  and  the  patient's  mental  con- 
dition was  quite  normal.  It  may,  however,  be 
advisable   in   some   cases    to    rapidly  diminish   the 


125 

dose  and,  perhaps,  to  substitute  injections  of  dis- 
tilled water  ;  or  sedatives,  other  than  morphia,  may- 
be tried.  In  one  case  recorded  by  W.  Keen,^  the 
sudden  interruption  of  morphia,  after  the  operation 
on  the  gangHon,  "produced  profound,  mental  de- 
pression ;  after  bromides,  strychnine,  and  chloral 
had  been  tried  without  success,  the  administration 
of  codeine,  in  doses  of  three-quarters  of  a  grain, 
calmed  the  hallucinations  and  pain." 

It  only  remains  to  notice  the  cases  in  which 
recurrence  of  epileptiform  neuralgia  has  followed 
on  the  same  side  as  the  operation.  These  can  be 
put  into  two  classes  ;  either  the  patient  was  neurotic 
or  hysterical  (z.^.,  not  really  a  suitable  subject  for 
the  operation),  or  the  operation  has  failed  to  deal 
adequately  with  (perhaps  has  never  even  touched) 
the  Gasserian  ganglion.  Of  the  former  there  are' 
a  few  examples  recorded.  For  instance.  Professor 
Krause  observed  recurrence  of  the  neuralgia  on 
the  side  operated  on  in  only  one  of  his  thirty-six 
cases  (reported  1903).  This  case  was  a  neuras- 
thenic medical  man,  in  whom  peripheral  operations 
had  been  fruitless.  Removal  of  the  Gasserian 
ganglion,  which  Krause  was  led  to  perform  against 
his  will,  had  no  better  result,  the  cause  of  the 
neuralgia  evidently  being  cerebral. 

Of  the  second  class,  that  in  which  a  wholly 
inadequate     operation     has     been     done    and    the 

^  Keen,  Trans.  Philadelphia  Med.  Soc,  1894. 


126 

neuralgia  has  returned,  many  more  instances  could 
be  quoted ;  indeed,  it  is  surprising  how  many 
have  been  published.  I  once  had  the  opportunity 
of  proving  that  in  a  supposed  excision  of  the  Gas- 
serian  ganglion,  performed  by  one  of  the  best 
operators  in  London,  the  ganglion  had  never  been 
reached.  The  patient  was  a  man  aged  50,  the 
subject  of  terribly  severe  neuralgia.  He  under- 
went the  operation  by  the  pterygoid  route  ;  it  was 
performed  in  two  stages  and  was  an  extremely 
protracted  affair,  owing  to  haemorrhage,  &c.  A 
short  respite  from  pain  followed,  and  it  was  fully 
believed  that  the  ganglion  had  been  dealt  with. 
However,  the  very  limited  ansesthesia  that  followed 
might  well  have  been  due  to  the  division  of  cuta- 
neous nerves  in  the  extensive  skin  incisions.  The 
patient's  neuralgia  returned  worse  than  ever.  He 
took  to  injecting  morphia  hypodermically  in  almost 
incredible  amounts,  and  became,  physically  and 
morally,  a  complete  wreck. 

After  his  disappointing  experience,  it  was  naturally 
difficult  to  induce  him  agfain  to  undergro  surgical 
interference,  and  I  expected  that  the  operation 
would  prove  unusually  difficult,  owing  to  the  pre- 
vious division  of  the  bone  round  the  foramen  ovale, 
&c.  This,  however,  did  not  prove  to  be  the  case. 
The  middle  fossa  had  been  perforated  about  half 
an  inch  to  the  outer  side  of  the  foramen  ovale, 
and  the  ganglion,  with  its  branches,  was  quite 
intact.     Nothing  could  be  a  stronger  commentary 


12/ 

on  the  difficulty  of  really  dealing  with  the  ganglion 
from  below  (by  the  pterygoid  route).  The  only 
trouble  I  experienced  in  this  operation  was  due  to 
haemorrhage,  chiefly  from  the  meningeal  artery. 
The  attempt  to  stop  this  bleeding,  by  plugging 
the  foramen  spinosum  with  wax  or  a  spicule  of 
bone,  failed,  and  I  therefore  tied  the  external 
carotid  in  the  neck.  The  two  maxillary  nerves 
were  then  divided  and  the  ganglion  excised. 

As  an  instance  of  the  slight  nature  of  the  shock 
following  this  operation,  this  patient  was  sitting  up 
and  writing  a  letter  within  twenty-four  hours  of  it, 
Although  he  had  got  used  to  injecting  eight  or 
ten  grains  of  morphia  per  diem,  he  was  fortunately 
resolute  enough  to  discontinue  the  practice  entirely 
as  soon  as  he  found  the  neuralgia  had  left  him. 
He  wrote  six  months  after  the  operation  :  "  From' 
being  a  hopeless  invalid,  I  have  become  as  strong 
and  well  as  at  any  time  during  my  life,  with  prac- 
tically no  pain.  I  have  never  touched  morphia 
since  the  operation  and  have  not  felt  the  least  desire 
for  it." 

It  is  now  (1904)  six  years  since  the  second 
operation,  and  the  patient  is  in  good  health  and 
free  from  any  recurrence. 

I  have  heard  of  some  other  cases  in  which,  after 
operation  by  Rose's  method  (the  pterygoid  route), 
the  neuralgia  was  supposed  to  have  been  cured, 
although,  subsequently,  recurrence  in  a  severe  form 
developed.     The  explanation  is,  that  the  ganglion 


128 

was  never  properly  dealt  with,  owing  to  the 
difficulties  due  to  haemorrhage  and  insufficient 
exposure.  The  same  criticism  applies  to  some 
cases  operated  on  by  the  temporal  route.  The 
sharp  spoon  is  an  instrument  which  has  been  used 
by  several  operators,  who  appear  to  think  that  the 
ganglion  is  readily  destroyed  by  a  little  indis- 
criminate scraping  in  the  region  of  the  cavernous 
sinus.  The  instrument  is  unsuitable  and  dangerous, 
and  should  never  be  employed  in  this  particular 
operation.  Failure  is  only  to  be  expected  if  the 
surgeon  relies  on  this  blind  groping  in  the  dark, 
instead  of  a  clean  dissection  of  the  ganglion. 
Equally  hazardous  and  uncertain  is  the  attempt  to 
twist  and  drag  away  the  ganglion  as  soon  as  one 
of  the  main  divisions  is  exposed. 

It  is  a  curious  fact  that  the  extensive  surgical 
interference  involved  in  trephining  the  skull,'  with 
its  attendant  loss  of  blood,  may  cause  the  neuralgia 
to  cease  for  days,  weeks,  or  even  months,  although 
the  ganglion  and  its  main  branches  have  been  hardly 
interfered  with  at  all.  The  real  test  of  success  is 
complete  anaesthesia  in  the  districts  normally  supplied 
by  the  divisions  of  the  fifth  nerve  concerned. 
Unless  this  anaesthesia  be  clearly  made  out  after 
the  operation,  recurrence  is  almost  certain  in  the 
future.  Now  and  then  the  operator  has  described 
division  of  the  roots,  whilst  sensation  was  perfectly 
retained  in  the  skin,  which  is  normally  supplied  by 
their  branches  {e.^.,  in  a  case  recorded  by  W.  Keen, 


129 

though  not  operated  on  by  him,  Chipault,  vol.  Hi., 
p.  694).  There  must  obviously  be  a  mistake  on 
the  part  of  the  operator  in  such  cases.  Gerster 
records  a  case^  in  which,  after  "destruction  of  the 
ganglion,"  sensation  recurred  within  a  month,  in 
both  second  and  third  divisions. 

In  a  case  published  by  M.  Lardy  (Chipault's 
Chirurgie  Ne7'^veuse,  vol.  ii.),  the  Gasserian  ganglion 
was  supposed  to  have  been  extirpated,  yet  sensation 
was  perfect  in  the  whole  area  supplied  by  the  fifth 
nerve.  The  patient  was  a  woman,  and  the  neuralgia 
"was  entirely  cured."  It  is  easy  for  the  operator  to 
persuade  himself  that  a  little  piece  of  dura  mater 
represents  the  ganglion.  It  is  impossible  to  believe, 
for  a  moment,  that  removal  of  the  Gasserian  ganglion 
can  be  attended  by  no  anaesthesia  in  the  skin  of 
the  face. 

The  difficulties  and  drawbacks  of  the  operation 
have  been  fully  discussed,  since  it  was  only  fair  to 
do  so.  But,  in  conclusion,  it  may  be  pointed  out 
that  few  procedures  in  the  whole  range  of  surgery 
are  so  successful  as  excision  of  the  ganglion  for 
true  epileptiform  neuralgia.  With  the  improved 
methods  of  operating  and  the  proper  selection  of 
cases,  the  risk  to  life  is  very  small,  and  the  prospect 
of  permanent  cure  is  great. 

By  limiting  the  excision,  and  sparing  the  oph- 
thalmic division,  whenever  possible,  the  risk  to  the 
eye  is  done  away  with. 

^Annals  of  Siivgevy,  Jan.,  1896,  p.  58. 


130 

The  deformity  which  results  is  hardly  worth  the 
name  ;  it  simply  amounts  to  atrophy  of  the  corre- 
sponding temporal  muscles.  The  introduction  of 
the  Hartley- Krause  method  forms  one  of  the  most 
important  surgical  gains  of  the  last  twenty-five 
years,  fertile  as  that  period  has  been  in  the  progress 
of  surgery. 


REFERENCE  TO  PUBLISHED  PAPERS  ON  THE 

SURGICAL   TREATMENT   OF   TRIGEMINAL 

NEURALGIA. 

Tiffany,  (L.  McL.)  Intracranial  operations  for  the  cure  of 
facial  neuralgia.  "Annals  of  Surgery,"  1896,  xxiv. 
575  to  736.  Details  are  given  of  108  cases,  collected  from 
various  sources. 

Sex  and  Age. — Patients  varied  in  age  from  20  years  to  79, 
few  being  younger  than  middle  life ;  males  v^^ere  very 
slightly  in  excess. 

Operation. — Two-thirds  subjected  to  the  Hartley-Krause 
operation,  nearly  one  fourth  to  that  of  Rose,  the  remainder 
to  other  methods.  There  were  forty-seven  operators, 
twenty-five  of  them  operating  once  each. 

Results. — Twenty-four  deaths,  causes  of  death  as  follows : — 
shock  8,  sepsis  8,  brain  trauma  3,  brain  abscess  (from 
trauma?)  i,  apoplexy  i,  cause  uncertain  3  cases. 

BiAGi,  L.  {II  PoUclinico,  November,  igoi).  Opposes  resection 
of  the  Gasserian  ganglion  on  account  of  its  dangers,  and 
advocates  dragging  away  the  main  branches  of  the  fifth 
nerve  instead.  He  narrates  three  cases  in  which  the 
latter  proceeding  was  carried  out  "  with  good  result." 

Fehleisen,  F.,  and  Westerfeld  ("  Report  of  the  Surg. 
Department  of  the  German  Hospital,  San  Francisco, 
1901.")  They  narrate  one  case  in  which,  after  removal 
of  the  Gasserian  ganglion,  sensation  returned  in  the 
peripheral  distribution  of  the  fifth  nerve,  although  at  the 
post-mortem,  removal  "  was  found  to  have  been  complete." 
No  explanation  is  suggested,  and  probably  a  very  simple 
one  would  suffice. 

Krause,  Fedor  ("  Verhandlungen  der  Deutschen  Gesellschaft 
fiir  Chirurgie  30  Kongress,"  1901).  An  important  account 
of  his  experience  up  to  that  date,  twenty-five  cases  of 
"typical  extirpation  of  the  Gasserian  ganglion."  The 
report  is  quoted  frequently  in  this  book. 


132 

Krause,  Fedor,  "  Die  Neuralgie  des  Trigeminus,  nebst  der 
Anatomie  und  Physiologie  des  Nerven,"  Leipzig,  i8g6, 
pp.  260,  with  two  photographs  and  50  illustrations  in  the 
text. 
Laguaite  {Lyon  Medicale,  1896,  Tome  83,  p.  375).  Ligature 
of  external  carotid,  Poirier's  method  followed,  whole  of 
ganglion  removed.  Neuralgia  was  cured,  but  the  eye 
was  lost. 

Keen  W.  W.  and  Spiller  W.  G.  [Amer.  Jouvn.  Med.  Sciences, 
1898,  vol.  cxvi.  p.  503).  Four  cases  reported,  two  fatal 
from  injury  to  bram  and  haemorrhage  during  operation. 
In  one  other  the  eye  became  ulcerated. 

Weeks,  S.  H.  [Trans.  Amer.  Surg.  Assoc,  1897,  vol.  xv.  p. 
171).  Interesting  case  reported.  Meningeal  artery  torn 
in  turning  down  flap  of  bone. 

Abbe,  "  Annals  of  Surgery,"  1896,  vol.  xxiii.  p.  60).  Two 
cases  recorded. 

Keen,  W.  W.  {Amer.  Journ.  of  Med.  Sciences,  1896,  vol.  cxi.  p. 
68).  Five  cases  recorded,  in  each  a  flap  of  bone  was 
turned  down,  and  in  every  one  profuse  haemorrhage  from 
meningeal  arteries  resulted  therefrom.  One  case  died 
from  septic  meningitis,  the  others  did  well.  In  one  case 
the  patient  had  sustained  eight  previous  operations  for 
the  neuralgia,  in  another  no  less  than  thirteen. 

Gerster,  A.  G.  "Annals  of  Surgery,"  1896,  vol.  xxiii.  p.  58. 
One  case  reported. 

Gerard-Marchant  {Bnll.de  la  Soc.  de  Chiv.,  1898,  vol.  xxiv.  p. 
884).  Three  cases :  all  recovered.  In  one  the  eye  was 
subsequently  lost  by  trophic  ulceration. 

Depage,  a.  {Bull.  Acad,  de  Med.  de  Beige,  1898,  4th  series,  p. 
294).     One  case,  severe  meningeal  haemorrhage,  recovery. 

Depage  {Ihid.  1897,  p.  687).  A  second  case,  in  which  the 
eye  was  subsequently  lost. 

Hutchinson,  J.,  Jr.  {Brit.  Med.  Joiivn.  Nov.  5th,  1898). 
Report  of  case  and  discussion  of  the  operation. 

Hutchinson  {Med.  Societys  Transactions,  1900,  pp.  274-282). 
Report  of  several  cases,  &c. 

Thomas,  J.  L.  {Bvit.  Med.  Journ.,  1899,  vol.  ii.  p.  1080).  Two 
cases  reported  of  excision  of  Gasserian  ganglion  :  in  both 
haemorrhage  was  severe  ;  in  one,  operation  could  not  be 
completed  on  this  account. 


133 

Thomas,  J.  L.  {Brit.  Med.Journ.,  1898,  vol.  i.  p.  487).  One  case, 
operation  not  completed  owing  to  severe  haemorrhage. 

MacLaurin,  C.  [Australian  Med.  Gaz.,  1901,  vol.  xx.  p.  36). 
Report  of  one  case  in  which  extra-cranial  operations  and 
trephining  had  previously  failed. 

Meyer,  W.  "  Annals  of  Surgery,"  1896,  vol.  xxiii.  p.  61. 
Interesting  case  of  sudden  death  from  temporo-sphenoidal 
abscess,  one  month  after  operation  on  the  Gasserian 
ganglion. 

MuGNAi  A.  ("7/  Policlinico,  1897,  p.  877.")    One  case  reported. 

Crawford  Renton,  J.  [Brit.  Med.  Joiiv.  1900,  vol.  ii.  p.  1435). 
One  successful  case. 

Renton  [Brit.  Med.  Jour.  November  i8th,  1904).  Note  on  case 
in  which  neuralgia  had  been  mainly  frontal,  and  in  which 
extensive  removal  of  supra-orbital  nerve  failed  to  relieve. 

Schwartz,  [Bull,  et  Mem.  Soc.  de  Chir.,  1898,  vol.  xxiv. 
p.  857.)  Case  reported  with  very  bad  result  (loss  of  eye 
&c.),  after  use  of  Doyen's  method. 

Spellissy,  J.  M.  "  Annals  of  Surgery,"  1900,  vol.  xxxi.  p.  463. 
Case  reported  in  which  external  carotid  artery  was  tied 
during  the  operation.     Result  good. 

Grieshammer,  [Munchener  Med.  Wochenschvift,  1901,  No.  20). 

Schwab,  Sydney  J.  ("The  pathology  of  trigeminal  neuralgia, 
illustrated  by  the  microscopic  examination  of  two  Gas- 
serian ganglia."     "  Annals  of  Surgery,"  June,  1901. 

Sir  Victor  Horsley  [The  Clinical  J ournal ,  1897,  vol.  xi.  pp.  8 
to  14,  and  17  to  23).  (Two  lectures,  giving  a  full  account 
of  the  operation  of  complete  excision  of  the  Gasserian 
ganglion  based  on  eight  personal  cases). 

Davis  [Univ.  of  Pennsylvania  Med.  Bulletin,  No.  2,  1904).  Dis- 
cussion of  the  various  modern  methods  of  operating  for 
trigeminal  neuralgia. 

Coelho  [Revue  de  Chir.  1897,  vol.  xix.  p.  623).  Case  of 
operation  in  two  stages.  The  cornea  became  opaque  but 
ultimately  cleared. 

Bland-Sutton,  J.  [Med.  Press,  1898,  vol.  i.  p.  549).  Success- 
ful case. 

Guenard,  a.  [Bnll.  de  la  Soc.  de  Chir.  1898,  vol.  xxiv.  p.  840). 
One  case,  not  very  clearly  reported. 

Jaboulay  [Lyon  Medicale,  1901,  vol.  xcvii.  p.  192).  Operation 
by  Poirier's  method  with  resection  of  the  zygoma. 


134 

The  following  papers  are  less  important,  or  inaccessible  to 
the  author. 

Barclay,    W.    M.    Surgical   treatment   of    Tic    Douloureux, 

removal  of  the   Gasserian  ganglion.     Bristol  Med.  Chir. 

Jour.  i8g6,  xiv.  55).      [This  paper  gives  a  tabulated  list 

of  thirty-seven  cases,  operations,  results,  &c.] 
Camineti,    R.    Recherches   sur    I'anatomie    chirurgicale    du 

ganglion  de  Gasser  ("  Trav.  de  neur.  Chir.  "  (Chipault), 

1900,  V.  323).      [No  cases] . 
Carson,  N.  B.  The  surgical  treatment  of  trifacial  neuralgia, 

with  report  of  a  case  of  removal  of  Gasserian  ganglion. 

{Med.  Rev.  St.  Louis,  1899,  xxxix.  199,  219). 
Chipault.     Resection,  du   ganglion     de   Gasser.      {Rev.   de 

Chirurgie,  1900,  xxii.  393.      [No  cases] . 
DiEULAFE.    Sur  une  cas  d'  extirpation  du  ganglion  de  Gasser. 

Arch.  Med.  de  Toulouse,  1897,  iii.  97. 
DoLLiNGER,  J.  Intercranielle  extirpation  du  ganglion  Gasseri. 

{Pest  Med.  Chir.  Presse,  i8gi,  xxxv.  177). 
DoLLiNGER,    J.   Die   intrakranielle   entfernung   des   ganglion 

Gasseri,  ohne  Unterbinding  der  arteria  meningea  media. 

Centr.    f.    Chirur,    1900,    xxvi.    1089,    ^^^"^    Brit.    M.    J. 

Epitome,  1901,  i.  18. 
Doyen.  On  extirpation  of  the  Gasserian  ganglion.     Travaux 

de  Neurologic  Chirurgicale  par  Chipault,  1898,  iii.  225. 

[No  cases] .     Resume  by  H.  P.  de  Forest,  "  Annals  of 

Surgery,"  1896,  xxiii.  69.      [No  cases] . 
Fergusson,    a.    H.    Removal    of    the    Gasserian    ganglion. 

Chicago  Med.  Rec.  1898,  xiv.  405. 
Friedrich    (P.    L.)    Krankengeschichten   und    Heilausgange 

nach   Resection   und  extirpation   des  ganglion    Gasseri, 

neuralgie — Recidiv    nach    ganglion-extirpation.       {Deut. 

Zeits.  f.  Chirur,  Hi.  1899,  360). 
Friedrich,  P.  L.  Zur  chirurgische  Behandlung  der  Gesichts- 

neuralgie,  einschlieslich   der  resektion  und   exstirpation 

des  ganglion  Gasseri.     {Mitt,  ad  Gvenzgeh.  d.  Med.  u.  Chir. 

Jena,  i8g8,  iii.  340). 
Halstead,    a.  E.   Removal  of  the    Gasserian   ganglion   for 

relief    of    trifacial    neuralgia,    with    report    of    a    case. 

Chicago  M.  Rec.  1897,  xiii.  389. 


135 

IsRAELsoN.    Zur  Casuistik  der  resection  des  ganglion  Gasseri 

bei  Trigeminus  neuralgia,  St.  Petersh.  Med.  Wochen.,  1897, 

xiv.  356. 
Jacob,  O.  Du  danger  de  leser   le  sinus  sphenoidal  dans   la 

resection  du  ganglion  de  Gasser,  Presse  Med.  1900,  ii.  3. 

[No  cases] . 
Jacob,  O.  Un    procede  de  resection  du  ganglion  de  Gasser. 

Rev.  de  Chimrgie,  1899,  xx.  29.      [No  casesj . 
Krogius.  Resektion  af  ganglion  Gasseri  for  en  svar  trigeminus 

neuralgi,  Finska  Jdksallsk  handl.,  Helsingfors,  1897,  xxxix. 

512. 
Lexer.    Zur   exstirpation  des   ganglion  semilunare  bei  Tri- 
geminus nenx Silgie,  Milnchen.  Med.  Wochens.,  1898,  xlv.  60. 
Meyer,    W.    Facial    neuralgia    cured    by    excision    of    the 

Gasserian  ganglion,  "  Annals  of  Surgery,"  1896,  xxiii.  58. 
Monari,  U.  Ein  fall  von  resektion  des  Gasser'  schen  ganglions.' 

Beitr.  ztiv  Klin  Chir.,  Tubingen,  1896,  xvii.  495. 
Murphy,    J.    B.    Surgery   of    the    Gasserian    ganglion   with 

demonstration,  report  of  two  cases,  Amer.  Med.  Surg.  Bull. 

N.  Y.  1896,  X.  437,  also  Southwest  Med.  Rec.  1896,  i.  345. 
PoiRiER,  P.  Resection  du  ganglion  de  Gasser,  arrachement 

protuberantiel  du  trijumeau,  Gaz.  des  Hop.   1896,  Ixix. 

808,  also  Btdl.  et  Mem.  Soc.  de  Chir.  1896,  xxii.  574.      [No 

cases.] 
Reed,  R.  H.  Successful  removal  of  the  Gasserian  ganglion, 

Colnmhiis  M .  J .  i^'^'j,  xviii.  113. 
Renton,  J.  C.  Notes  of  the  cases  of  excision  of  the  Gasserian 

ganglion   for   epileptiform   neuralgia,  B.  M.  J.  1900,  ii. 

1435- 
Rose,   W.   On  the  practical  value  of  extensive  removal   of 

nerve  trunks   in   the   operative  treatment  of  trigeminal 

neuralgia.  Practitioner,  1899,  Ixii.  255.      [No  cases] . 
Schwartz,  Ablation  du  ganglion  de  Gasser  pour  une  nevralgie 

trifaciale  rebelle.     Insucc^s  therapeutique,  troubles  ocu- 

laires,  Bull,  et  Mem.  de  la  Soc.  de  Chir.  1898,  xxiv.  859. 
Serrate,  L.  Intervencion  quiriirgica  en  el  ganglio  de  Gasser, 

Rev.  de  Med.  y  drug,  prdct.  Madrid,  1898,  xlii.  565. 
Weeks,   S.   H.  Removal  of  the  Gasserian  ganglion,   Trans. 

Amer,  Surg.  Assoc.  1897,  xv.  171. 


136 

W6LFLER.    Demonstration    eines  Falles   von  resection  eines 

ganglion  Gasseri,  Pvag.  Med.  Wochens.     1898,  xxiii.  178. 
Yarre,  C.   Ueber  nervenregeneration   nach    extirpation    des 

ganglion    Gasseri   als    Ursache   recidirender   trigeminus 

neuralgie,    Vevhandl.   d    Dent.    Gesell.  f.    Chinirgie,    1899, 

xxviii.  256. 
Sapeszko,  K.,  papers  in  Russian,  one  of  which  is  abstracted 

in  the  CentralblaU  fiiv  Chinirgie,  1901,  No.  16. 
ScHLOFFER,    H.     "  Zur    Technik  der   Trigeminusresektion " 

[Prague  Med.  Wochenschrift,  igoi,  No.  44). 
Serenni,  W.  {CentralblaU  filr  Chinirgie,  1901,  No.   16).     One 

case  only  is  recorded. 
Spiller,  G.  and  H.  Frazier.    "  The  Division  of  the  Sensory 

Root  of  the  Trigeminus  for  the  Relief  of  Tic  Douloureux," 

Pennsylvania  Med.  College,  Dec,  1901. 
ViLlar.    (Revue  de  Chinirgie,  1901,  No.  11). 
Bougle.    {Bull,  et  Mem.  de  la  Soc.  de  Chirurgie,  1901,  No.  14). 


IN  DEX. 


Abbe,  Dr.  R.,  removal  of  Gasserian  ganglion,  method,  95-96. 

Acid  fermentation  round  the  neck  of  a  tooth,  neuralgia  due  to,  13. 

Adrenalin,  85. 

Air  sinuses,  inflammation  of,  causing  neuralgia,  5. 

Alcohol,  relation  to  epileptiform  neuralgia,  24. 

Allbutt's  "  System  of  Medicine,"  cited,  3. 

Alveolar  suppuration,  neuralgia  due  to,  12. 

Amer.  Journal  of  Med.  Science,  cited,  92  note'',  no,  115. 

Ammonium,  iodide  of,  14. 

Anaemia,  neuralgia  due  to,  2,  4. 

Anaesthesia.     See  also  Cutaneous  Anaesthesia. 

Region  of,  after  resection  of:  superior  maxillary  nerve,  72  ;  inferior  maxil- 
lary nerve,  73. 

Tabetic  neuralgia,  following,  12. 

Tumour  pressure  on  Gasserian  ganglion,  in  cases  of,  31,  36,  38. 
Anaesthetic  for  use  in  excising  Gasserian  ganglion,  78. 
Andrews,  G.  : 

Corneal  ulcers  following  extirpation  of  Gasserian  ganglion,  case  of,  1 10. 

Temporary  oculo-motor  paralysis,  case  recorded  by,  1 18. 
Aneurism  needle,  diagram  of,  79. 
"  Angiolithic  Sarcoma,"  37. 

"  Annals  of  Surgery"  cited,  61,  80,  95,  116,  117,  118  note",  129. 
Anstie,  Dr.,  cited,  23  note,  24. 

Anterior  lacerated  foramen,  osteo-sarcoma  connected  with  bone  of,  32. 
Antrum  of  Highmore  : 

Suppuration  in  :  case  of,  quoted,  5  ;  region  of  pain  from,  5. 

Trephining,  to  reach  the  pterygo-maxillary  fossa,  Carnochan's  method  of, 
58-61,  66. 
Aphasia,  following  extirpation  of  Gasserian  ganglion,  87  ;  case  of,  121. 
Arterio-sclerosis  as  a  cause  of  epileptiform  neuralgia,  28. 
Astigmatism,  3. 

Ataxia,  spasmodic  neuralgia  in  limbs  and  trunk  with,  II. 
Atrophy  of  right  eye  in  tumour  of  Gasserian  ganglion,  32. 
Auditory  meatus,  external : 

Insensitive  area  after  excision  of  Gasserian  ganglion,  104-5. 

Relation  of,  in  trephining  skull  to  excise  Gasserian  ganglion,  81. 


138 

Auditory  nerve,  division  of,  for  vertigo,   cutting  of  facial  trunk  in  operation 

of,  98. 
Avulsion  of  fifth  nerve  branches  in  epileptiform  neuralgia,  45. 

Beitrdge  zur  Klinische  Chirurgie,  cited,  29. 
Belladonna,  administration  of,  in  epileptiform  neuralgia,  39. 
Bernandi,  fatal  cases  of  excision  of  Gasserian  ganglion,  114. 
Billroth,  Prof.,  cited,  15  note,  19,  22,  23,  28,  29,  43,  46,  66. 
Biondi,  extirpation  of  Gasserian  ganglion  by. 

Brain,  effects  of  pressure  on,  during  operation,  117. 

Corneal  ulcer  following,  case  of,  no. 
Blood,  abnormal  conditions  of,  producing  neuralgia,  2. 

Blood-vessels,  degenerative  changes  in,  as  a  cause  of  trigeminal  neuralgia,  28, 
Bone,  caries  or  necrosis  of,  causing  neuralgia,  13. 
Bougie,    corneal   ulcers   with    chemosis    following    extirpation   of    Gasserian 

ganglion,  case  of,  in. 
Boyd,  Mr.  Stanley,  54,  72. 

Brain,  injuries  to,  in  operating  on  Gasserian  ganglion,  danger  of,  92. 
Brit.  Med.  Journal,  cited,  68  note '. 
Bull.  Acad,  de  Med.  de  Beige,  cited,  no. 
Bull,  de  la  Soc.  de  Chir.,  cited,  no,  in. 
Bull,  et  ma?i.  de  la  Soc.  du  Chir.,  cited,  57  note. 
Buzzard,  Dr.,  cited,  11  andnote^,  12. 

Caffein,  preparations  of,  in  neuralgia,  15. 

Cancer  of  the  tongue,  57. 

Cannabis  indica,  administration  of,  in  minor  neuralgia,  14. 

Caponotto,  cases  recorded  by  : 

Cholesteatoma  causing  neuralgia,  35. 
Injury  to  Eustachian  tube,  loi. 
Carious  teeth,  neuralgia  due  to,  2,  12-13,  22. 
Carnochan,  intracranial  excision  of  superior  maxillary  nerve,  method  of,  58- 

61,  65,  66. 
Carotid  artery,  pressure  on,  in  tumour  of  Gasserian  ganglion,  31. 

„         „         common,  ligature  of:  in  excising  Gasserian  ganglion,  88:  as 

a  treatment  for  neuralgia  of  fifth  nerve,  99-100, 
„         „         external,    hgature   of,    advisability   of,    in    excising  Gasserian 

ganglion,  96-99. 
,,      canal,  absorption  of  wall  of,  in  tumour  of  Gasserian  ganglion,  34. 
Cavernous  sinus  : 

Hemorrhage  due  to  opening  of,  116. 

Laceration  of  wall  of,  in  excising  Gasserian  ganglion,  danger  of,  96,  119- 

120. 
Nerves  in  wall  of,  inflammation  of,  10. 
Tumour  in  region  of,  11,  31,  37- 
mentioned,  85. 
Cavum  Meckelii,    division   of  sensory  portion    of    Gasserian   ganglion   in  or 
above,  98. 


139 

Cephalalgia,  persistent,  cases  of,  quoted^  6-7. 

Cerebral  artery,  middle,  case  of  hsemorrhage  from,  induced  by  perforation  of 
the  skull,  92.  • 
,,         hemisphere,  right,  extravasation  of  blood  into,  from  brain  pressure 
during  operation,  117. 
Cerebro-spinal  fluid,  escape  of,  in  operating  on  Gasserian  ganglion,  37,  86, 

109,  119. 
Cervical  sympathetic  ganglia,  excision  of,  in  facial  neuralgia,  100. 
Chavasse,  Mr. ,  cited,  58  and  note  ^. 
Chiene,  Prof.,  cited,  67. 
Chipault : 

Chirttrgie  Nerveuse,  cited,  90  note ;  92  note^,  93  and  note'',  97,  115.  118 

nole^,  129. 
Cited,  on  :  excision  of  cervical  sympathetic  ganglia  in  trigeminal  neuralgia, 
100  and note^  \  mortality  after  excision  of  Gasserian  ganglion,  112. 
Chisel,  use  of,  53. 

Cholesteatoma,  of  pons  varolii,  35  ;  of  petrous  bone,  36. 
Chondro-sarcoma  invading  Gasserian  ganglion,  31-32. 
Chorda-tympani  nerve,  taste  organs  supplied  by,  107. 
Climacteric  in  women,  neuralgia  due  to,  4. 
Clinica  Chirurgica,  cited,  121. 
Clinical  Journal,  cited,  28, 

Codeine,  administration  of,  after  sudden  interruption  of  morphia,  125. 
Codivilla,   cited,  29,  87  ;  intra-cranial  resection  of  inferior  maxillary  division 

of  fifth  nerve,  73. 
Coelho,   S.,  cited,   133  ;    corneal  opacity  following  extirpation  of  Gasserian 

ganglion,  case  of,  no. 
Collins,  Dr.  H.  D.,  case  recorded  by,  117. 
Conjunctiva,  sensation  retained  in,  after  partial  excision  of  Gasserian  ganglion, 

104. 
Conjunctivitis,  following  total  excision  of  Gasserian  ganglion,  in. 
Cook,  Dr.,  quoted,  62-63. 
Cornea  : 

Sensation  retained  by,  after  partial  excision  of  Gasserian  ganglion,  104. 
Ulceration  of  :  following  total  extirpation  of  Gasserian  ganglion,  cases  of, 
lio-lil  ;  accompanying  trigeminal  neuralgia,  26-27. 
Coronoid  process,  division  of,  loi. 
Cryer's  drill,  92. 
Gushing,  Dr.  : 

Anaesthetic  area  after  excision  of  Gasserian  ganglion,  105-106. 
Method  of  removing  Gasserian  ganglion,  89-90,  loi. 
Taste,  perception  of,  after  removal  of  Gasserian  ganglion,  107. 
Cutaneous  anaesthesia  after  excision  of  Gasserian  ganglion,  area  of,  after  total 
excision,  103-104  ;  after  partial  excision,  104-105  ;  question  of  decrease 
in  area,  106. 

Dahlgren's  cutting  forceps,  93. 

Damp,  influence  of,  in  intensifying  pain  of  epileptiform  neuralgia,  48. 


I40 

Davis  : 

Cases  recorded  by:  corneal  ulcer  following  extirpation  of  ganglion,  no  ; 
oculo-motor  paralysis  after  extirpation,  Il8. 

Cited,  133. 
Deaver,    Dr.,    on   peripheral   operations   for  epileptiform   neuralgia,    45-46; 

Surgical  Anatomy,  cited,  44. 
Delirium,  25. 
Dental  nerve,  inferior,  resection  of,  74. 

,,      neuralgia.     See  Minor  neuralgia. 
Depage,  A.,  case  of  corneal  ulcer  following  excision  of  Gasserian  ganglion, 

no. 
Dercum,  cited,  35  note. 
Deutsche  Med.  Woch.,  cited,  76  note"^. 
Dieulafe,  cited,  134. 

Diplopia  following  extirpation  of  Gasserian  ganglion,  121. 
Doyen  : 

Operation  for  removing  Gasserian  ganglion,  88. 

Perforator,  pattern  of,  93. 
Dura  mater  : 

Exposure  of,  in  trephining  wall  of  temporal  fossa,  ']\. 

Detachment  of,  in  exposing  Gasserian  ganglion,  81,  83-84. 

Injury  to,  in  breaking  down  skull  wall,  danger  of,  81,  91. 

Laceration  of,  in  removing  Gasserian  ganglion,  119. 

Sarcoma  of,  35  ;  cases  of,  25,  36-37. 

Tumours  involving,  36,  37. 

Ear,  sensation  retained  by,  after  removal  of  Gasserian  ganglion,  103-104. 

Electric  drills  and  cutters,  danger  of,  93. 

Electricity  in  treatment  of  epileptiform  neuralgia,  16,  39. 

Elevators,  diagram  of,  79. 

Empyema  of  sinuses,  neuralgia  due  to,  5. 

Endothelioma  of  Gasserian  ganglion,  36-37  ;  case  of,  35-36- 

English,  Mr.  T.  Crisp,  cited,  70. 

Epilepsy,  relation  to  epileptiform  neuralgia,  23-24. 

Epileptiform  neuralgia : 

Age  of  onset  of,  23. 

Causation,  24-25,  43. 

Characteristics  of,  12,  17-18.  19,  121. 

Climate,  influence  of,  21. 

Dental  neuralgia  simulating,  13  ;  relation  to,  24. 

Differential  diagnosis  of,  3. 

Epilepsy,  true,  relation  to,  23-24. 

Exciting  causes  of,  19. 

Eye  changes  in,  26-27. 

Facial  muscles,  afiection  of,  in,  23. 

History  of  case  of,  and  its  treatment,  46-50. 

Ignorance  as  to  pathology  and  causation  of,  1-2. 

Liability  to  attacks,  23. 


141 

Epileptiform  neuralgia — continued. 

Medicinal  treatment  of,  14-15,  39-40. 
Mental  and  moral  degeneracy  due  to,  19-21. 
Migraine  contrasted  with,  23. 
Operative  treatment  of : 

Extra-cranial  operations  : 

Avulsion  of  fifth  nerve  peripheral  branches,  44-45. 
Inferior  dental  nerve,  on,  see  that  title. 
Ligature  of  common  carotid  artery,  99-100. 
Neurotomy,  42-43. 
Resection  of  nerves,  43,  45. 
Superior  maxillary  nerve,  on,  see  that  title. 
Temporary  nature  of  results,  45-48. 
Cervical  sympathetic  ganglia,  excision  of,  100. 
Intra-cranial  operations  : 

Gasserian  ganglion,  extirpation  of,  see  that  title. 
Inferior  maxillary  nerve,  on,  see  that  title. 
Superior  maxillary  nerve,  on,  see  that  title. 
Reference  to  published  papers,  131-134. 
Pain  in  : 

Character  of,  2,  48. 
Distribution  of,  4,  21-22. 

Tumours  of  Gasserian  ganglion,  resemblance  to  pain  of,  31. 
Pathology ; 

Degenerative  changes  in  nerves  and  ganglia,  27-30. 
Eye-changes,  26-27. 

Neuritis,  theory  as  to  causation  from,  26-29,  96. 
Vascular  degeneration,  28. 
Recurrence  of,  on  the  same  side  after  removal  of  Gasserian  ganglion,  125- 

129. 
Simulation  of,  40-41. 
Transference  of,  to  opposite  side  after  removal  of  Gasserian  ganglion, 

cases  cited,  121-124. 
Treatment  of,  see  subheadings,  medicinal  and  operative. 
"  Trophic"  symptoms,  26. 
"  Essai  sur  les  Symptomes  Cephaliques  de  Tabes  Dorsalis,"  Pierret,  cited, 

1 2  and  note. 
Etat  Actuel  de  la  Chir.  Nerveuse  (Chipault),  cited,  93  note^. 
Ethmoidal  air  sinus,  inflammation  of,  5. 
Eustachian  tube : 

Danger  of  injury  to,  in  Rose's  pterygoid  operation,  loi. 
Sensation  in,  after  excision  of  Gasserian  ganglion,  105. 
Eye  lesions  following  total  extirpation  of  Gasserian  ganglion,  108-12. 
Eye  symptoms  in  epileptiform  neuralgia,  26-27,  70- 

Eyelid,    upper,    sensation    retained  by,    after   partial   excision    of    Gasserian 
ganglion,  104-5. 

Females,  liability  of,  to  epileptiform  neuralgia,  18. 


142 

Fibrillary  tremor  of  facial  muscles,  23. 
Fifth  Herve : 

Gasserian  ganglion.     See  that  title. 

Involvement  of,  in  epileptiform  neuralgia,  21-22,  67. 

Neuritis  of,  9. 

Operations  on,  see  Epileptiform  neuralgia — operative  treatment. 

Region  of  pain  in,  in  tabetic  neuralgia,  12. 

Sarcoma  of  Gasserian  ganglion,  involvement  in,  34-35. 
Finlay,  Dr.,  7. 

Finney,  L.  J.,  fatal  cases  of  excision  of  Gasserian  ganglion  by,  114. 
Foramen  ovale : 

Exposure  of,  in  excising  Gasserian  ganglion,  49,  89,  90. 

Position  with  regard  to  :  foramen  rotundum,  83  ;    foramen  spinosum,  94. 

Plugging  of,  97. 

Relation  of,  in  incising  for  removal  of  Gasserian  ganglion,  82. 

Variations  in  size,  shape  and  position  relative  to  foramina  rotundum  et 
spinosum,  82,  83. 

mentioned,  71. 
Foramen  rotundum : 

Exposure  of,  in  excising  Gasserian  ganglion,  49. 

Position  with  regard  to  foramen  ovale,  83. 

Plugging  of,  95-97. 

Relation  of :  in  excision  of  Gasserian  ganglion,  89  ;  in  excision  of 
superior  maxillary  nerve,  60,  61  ;  in  trephining  wall  of  temporal  fossa, 
71 ;  in  incising  for  removal  of  Gasserian  ganglion,  82  ;  in  Storrs'  extra- 
cranial operation  on  the  superior  maxillary  nerve,  63. 

Variations  in  size,  shape,  and  position  relative  to  foramina  ovale  et 
spinosum,  82,  83. 

mentioned,  65,  69.  ' 

Foramen  spinosum,  71,  82,  83,  84,  94. 
Forceps,  diagram  of,  79. 

Forehead,  sensation  retained  in,  after  partial  excision  of  Gasserian  ganglion,  104. 
Fowler,  G.  R. ,  cited,  68  and  note'' ,  99,  114,  115. 
France,  method  of  extirpating  Gasserian  ganglion  in,  93. 
Frazier,  C.  H.,  retractor  devised  by,  80. 
Freezing  the  skin  in  minor  neuralgia,;  16. 
Frontal  bone,  5,  81. 

„      neuralgia,  3,  4-5. 
Frontal  sinus  : 

Anterior  wall  of,  trephining  of,  42. 

Inflammation  of,  neuralgia  due  to,  6. 

Galvanism,  16. 
Gasserian  ganglion  : 
Extirpation  of — 
Complete  : 

Cavernous  sinus,  danger  of  lacerating  wall  of,  119-120. 
Corneal  ulceration,  danger  of,  109- 112. 


143 

Gasserian  ganglion :  continued. 

Extirpation  of — continued. 

Complete :  continued. 

Cushing's  method,  89-90. 
Horsley,  Sir  Victor,  method  of,  86. 
Keratitis  following,  risk  of,  108-111. 
Oculo-motor  complications  following,  118- 1 19. 
Sensation,    recurrence    of,  in  peripheral  branches   of  fifth 
nerve  case  cited,  131. 
Cutaneous  anaesthesia  after,  area  of,  103-105. 
Disfigurement  after,  103,  129. 
Dura  mater,  danger  of  lacerating,  119. 
France,  methods  employed  in,  93. 
Mortality  following,  93,  95,  loo,  112  et  seq. 
Osteoplastic  method,  91  ;  "pressure  paralysis  "  following,  117. 
Partial : 

Codivilla's  operations,  73. 

Intradural  division  of  roots  (Sir  V.  Horsley),  97. 

Ophthalmic  division,  sparing  : 

Advantages  of,  119,  120,  129. 
Hartley- Krause  temporal  method  : 
Case  quoted,  85-86. 
Description  of,  77  et  seq. 
Disfigurement  after,  103. 
Gain  to  surgery  of,  130. 
Haemorrhage,  severe,  in,  87. 
History  of  operation,  75-76. 
Precautions  necessary,  87,  116-117. 
Treatment  after  operation,  85. 
Two  stages,  dividing  operation  into,  87-88. 
Krause,  Prof.,  method  of,  76-77,  94. 
Plugging  of  foramina  rotundum  et  ovale,  95,  97. 
Prognosis  of,  129. 

Sensory  root,  alone,  division  of,  97-98. 
Permanency  of  results  obtained  by,  46. 
Recurrence  of  neuralgia  on  same  side  after,  125-129. 
Rose's  pterygoid  method,  loi,  103,  126-128. 
Temporol-sphenoidal  abscess  following,  133. 

Transference  of  neuralgia  to  the  opposite  side  after,  cases  cited,  121-124 
Upright  position  of  patient,  importance  of,  99. 
Various  methods  as  to,  88. 
otherwise  mentioned,  2-3,  13,  17,  18,  68. 
Pathological  changes  observed  in  epileptiform  neuralgia,  27-30, 
Pressure  atrophy  of,  37. 
Resection  of  nerves,  exposure  in,  71,  73. 
Sarcoma  of,  case  of,  33-35. 
Tumours  involving,  31. 
Gauze,  plugging  with,  danger  of,  114,  119. 
Gelsemium,  administration  of,  in  neuralgia,  14-15,  39. 


144 

Gerard-Marchant,  no. 

Gerster,  A.  G.,  cases  recorded  by,  114,  129. 

Gigli's  saw,  91. 

Glaucoma,  acute,  neuralgia  due  to,  3-4. 

Gout,  2,  24. 

Guinard,  A.,  cited,  107  note'^. 

Gums,  ulceration  of,  13. 

Gustatory  nerve  : 

Neurectomy  of,  57. 

Paralysis  of,  interference  with  perception  of  taste  after,  106-108. 

HAEMORRHAGE,  87,  lOI,  II4-I16. 

Hagelstan,  cited,  36. 

Hartley,  Dr.  F.,  removal  of  Gasserian  ganglion,  76  and  note '  ;  oculo-motor 

paralysis  after  excision,  case  recorded,  n8. 
Hartley-Krause  method  of  extirpating  Gasserian  ganglion,  36,  102. 
Head,  Dr.  H.,  cited,  3,  4  and  note,  5,   18  and  note,   19,  23,  29,  31,  41,  50  ; 

quoted,  6,  9. 
Headache  : 

Eye-strain,  due  to,  4. 

Syphilitic,  treatment  of,  6. 
Hemiplegia : 

Danger  of,  following  ligature  of  common  carotid  artery,  100. 

Temporary,  due  to  pressure  on  brain  in  operating,  117. 
Herpes  frontalis,  i,  2,  4,  5,  27. 
Hoffmann's  bone-cutting  forceps,  78,  82. 
Homen,  cited,  37. 
Horsley,  Sir  Victor  :  ^ 

Cited,  14,  22,  24,  28. 

Gasserian  ganglion,  operations  on,  mortality  statistics  for,  113. 

Gelsemium  in  treating  neuralgia,  on,  39.  ^ 

Intradural  division  of  ganglionic  roots  by,  75-76,  97. 

Quoted,  86  and  note. 
Horsley's  aseptic  wax,  94. 

Hutchinson,  Dr.  J.  C.,  case  of,  cited,  lOO  and  note  ^. 
Hysterical  neuralgia,  3,  40-42. 
Hypermetropia,  3,  4. 

Inferior  dental  nerve  : 

Liability  to  epileptiform  neuralgia,  42. 

Neurectomy  of :  intrabuccal  method,  51-52;  Montenoveri's  method,  52  : 

trephine  aperture  in  lower  jaw,  through,  52-53  ;  case  quoted,  54-55- 
Stretching  of,  in  epileptiform  neuralgia,  47. 
Inferior  maxillary  division  of  fifth  nerve,  intracranial  resection  of,  73,  74,  102. 
Influenza,  5. 
Infra-orbital  artery,  62. 

,,  foramen,  59,  64. 

,,  nerve : 

Liability  of,  to  epileptiform  neuralgia,  42. 


H5 

Infra-orbital  nerve—  continued. 
Removal  of,  47. 
Resection  of,  43-44,  74. 

Tracing  superior  maxillary  nerve  by,  method,  58-61. 
Mentioned,  58,  62,  64,  65,  66. 
Infra-temporal  crest,  82,  93. 

Insanity,  relation  to  epileptiform  neuralgia,  24-25. 
Internal.  Med.  Mag.  Philad.,  cited,  no. 
Intracranial  gummala,  neuralgia  due  to,  9. 

Instruments,  bone-elevator,  60  ;  bradawl,  carpenter's,  60  ;  chisel  and  mallet, 
59,  60  ;  Cryer's  drill,  92  ;  Dahlgren's  cutting  forceps,  93  ;   director,  60, 
61  ;  Doyen's  perforator,  93  ;  electric  drills  and  cutters,  danger  of,  93  ; 
forceps,  58  ;    Gasserian   ganglion,    for   removal  of,   78-80,  93  ;    Gigli's 
saw,   91  ;  Jarvis  snare,  63 ;   scissors,  60,  61  ;    Thiersch's  forceps,  44 ; 
trephine,  60. 
Iodides,  in  treatment  of  neuralgia  of  syphilitic  origin,  14;  in  syphilis,  6,  8. 
Iridectomy,  4. 
Iritis : 

Neuralgia  due  to,  3-4. 
Syphilitic  origin  of,  7. 
Italian  surgeons,  method  of  removing  Gasserian  ganglion  in  vogue  with,  95. 

Jarvis  snare,  63. 
Jaw,  lower : 

Condyle  of,  relation  to  incision  for  extirpating  ganglion,  80,  81. 

Coronoid   process,    removal   of,    in   excision   of    Gasserian   ganglion   by 
Cushing's  method,  90. 
Jaw,  upper,  22,  58. 
Jaws,  neuralgic  pain  in,  4. 

yohns  Hopkins  Hospital  Bulletin,  cited,  107  note  ',  114. 
Journal  of  Amer.  Med.  Assoc,  cited,  89  note. 

Keen,  Prof.  W.  W.  : 

Cited,  26,  27,  29,  35  note,  36,  92  note\  99,  113,  121. 

Corneal  ulcers  following  extirpation  of  Gasserian  ganglion,  no 

Fatal  cases  of  ganglion  excision,  115. 

Morphia,  interruption  of,  after  operation  on  ganglion,  125. 
Keratitis  following  total  extirpation  of  Gasserian  ganglion,  108-I11. 
Kocher,  Prof.,  cited,  90. 
Kosinski,  cited,  31  and  note,  32. 
Krause,  Prof.  : 

Cited,  15,  18,  19,  29,  37,  45,  97. 

Gasserian  ganglion,  extirpation  of,  methods,  cases  recorded,  &c.,  68,  76 
andnote"^;  87,  93,  in,  H2,  117,  118,  119,  125. 

Retractor  of,  80  ;  diagram,  79. 

Lancet,  cited,  75. 

Lange,  fatal  case  of  excision  of  Gasserian  ganglion,  115. 


146 

Lampiasi,  cited,  35  and  note. 

Lardy,  M.,  case  of  extirpation  of  ganglion  unattended  by  anaesthesia,  129. 

Lauwers,  cited,  44  note". 

"  Lectures  on  Clinical  Medicine"  (Trousseau)  quoted,  43  and  note^. 

Lexer,  removal  of  Gasserian  ganglion  by  : 

Mortality  among  cases,  112,  113. 

Oculo-motor  paralysis  after,  cases  recorded,  118. 

Recurrence  of  neuralgia  after,  121. 
Limbs,  lower,  pain  in,  in  endothelioma  of  Gasserian  ganglion,  36. 


Mackenzie,  Dr.  F.  M.,  122. 

Major  neuralgia,  see  epileptiform  neuralgia. 

Malar  bone,  58,  65. 

Malaria,  2. 

Males,  liability  of,  to  epileptiform  neuralgia,  18. 

Maryland  Med.  Journal,  cited,  121  note. 

Masseter  muscle,  paralysis  of,  after  excision  of  Gasserian  ganglion,  106. 

Masseteric  region,  sensation  retained  in  after  removal  of  Gasserian  ganglion, 

103-104. 
Masticatory  muscles,  paralysis  of,  after  excision  of  Gasserian  ganglion,  106, 

108  ;  one-sided  paralysis,  98. 
Mears,  Dr.  Ewing : 

Case  of,  cited,  56. 

Removal  of  Gasserian  ganglion  first  suggested  by,  75. 
Meatus,  anterior  wall  of,  insensitive  area  after  excision  of  Gasserian  ganglion, 

105. 
Meckel's  ganglion,  case  of  removal  of,  47. 
Median  otitis,  36. 

Medical  Record  of  New  York,  cited,  114,  115. 
Medical  Times,  cited,  114. 

Medico-Chirurgical  Soc.  Transactions,  cited,  58  note'^. 
Meningeal  artery : 

Division  of,  in  removing  Gasserian  ganglion,  49,  84,  94-95. 

Hsemorrhage  from,  controlling,  86. 

Injury  to,  in  removing  ganglion,  danger  of,  81,  90,  92-93,  132. 
Meningitis,  septic,  following  excision  of  Gasserian  ganglion,  37,  114,  115. 
Mental  and  moral  degeneration  due  to  epileptiform  neuralgia,  19-21,  24-25. 
Mental  defect,  case  of,  following  total  extirpation  of  Gasserian  ganglion,  121. 
Menthol,  15. 

Mercury,  syphilis  treated  by,  6,  7,  8. 
Mesotan,  15. 
Meyer,  W.,  115. 
Migraine,  3,  23. 
Minor  neuralgia : 

Causes  of,  12-14,  22. 

Epilepsy,  relation  to,  24. 

Treatment,  14-16. 


147 

Monari,  died,  29  and  nole. 

"  Monograph  on  Neuroma,"  R.  W.  Smith,  quoted  32  and  note,  35. 

Montenoveri,  52. 

Morphia  : 

Administration  and  injection  of,  15,  39-40,  85. 

Sudden  interruption  of,  124-125. 
Mortality  from  operations  on  the  Gasserian  ganglion,  93,  95,  96. 
Mouth,    ansestliesia   of  mucous   membrane   of,    after    excision   of    Gasserian 

ganglion,  105. 
Mugnai : 

Cited,  87. 

Infra-orbital  nerve,  resection  of,  43  and  note  -. 

Intra-cranial  excision  of  superior  maxillary  nerve,  method  of,  63-66,  67. 

Oculo-motor  paralysis  following  total  extirpation  of  ganglion,  118. 
Myelin-sheaths  of  nerves,  degenerative  changes  in,  in  epileptiform  neuralgia, 
27,  29. 


Necrosis,  syphilitic,  involving  base  of  skull,  8-9. 
Nerves  : 

Local  applications  in  minor  neuralgia,  15-16. 

Pathological  changes  observed  in  epileptiform  neuralgia,  27,  28,  29. 

Right  facial  and  trigeminal,  paralysis  of,  32. 
Neuralgia  : 

Causes  of,  classification  of,  2-3. 

Epileptiform,  see  that  title. 

Dental  causes,  due  to,  see  Minor  Neuralgia. 

Eye-strain,  due  to,  3. 

Syphilis,  treatment  of,  6. 

Tabetic,  11- 12. 
"  Neuralgia  des  Trigeminus,  Die,"  cited,  76  and  ttote-. 
Neurectomy,  13,  19,  44. 

Neurotomy  in  cases  of  epileptiform  neuralgia,  42-43. 
Neuritis,  2,  9,  26-27,  96. 

New  York  Med.  Journal,  cited,  68  note'',  76  note^. 
Nicholson,  W.  P.,  fatal  cases  of  excision  of  ganglion  of,  115. 
Nodes  of  the  skull,  8. 

Nose,  area  of  cutaneous  ansesthesia  in,  after  excision  of  Gasserian  ganglion, 
104,  105. 


Oculo-motor  nerves : 

Danger  of  injury  to,  in  complete  extirpation  of  Gasserian  ganglion,  96. 

Involvement  of,  in  tumour  of  Gasserian  ganglion,  31,  32,  35,  38. 

Paralysis  of,  31,  35,  118- 1 19. 
Oleic  acid,  15. 
Olive  oil,  15. 
"Operative  Surgery,"  Treves,  cited,  58  note^. 


148 

Ophthalmic  division  of  Gasserian  ganglion,  removal  of,  unnecessary  in  epilep- 
tiform neuralgia,  22,  84,  86,  95,  104-105. 
,,  ,,         of  fifth  nerve,  involvement  of,  in  sarcoma  of  Gasserian 

ganglion,  34  ;  neuralgia  not  transferred  to,  after  resec- 
tion of  superior  or  inferior  branches,  68-69  !  neuralgia 
invohang,  unsuitability  of  cases  of,  for  removal  of  Gas- 
serian ganglion,  77. 

Ophthalmological  Society'' s  Transactions,  cited,  \o  note,  11. 

Ophthalmoplegia,  case  demonstrating  pathological  nature  of,  lo-ii. 

Opium,  epileptiform  neuralgia  treated  by,  39-40. 

Orbital  circulation,  obstruction  of,  in  tumour  pressure  on  Gasserian  ganglion, 
381. 
,,      margin,  58. 

Osmic  acid,  hypodermic  injection  of,  16. 

Osteo-sarcoma  involving  Gasserian  ganglion,  removal  of,  32.     . 


Pain  : 

Causes  of,  distinguishing  between,  i. 

Character  of,  in  different  forms  of  neuralgia,  2  ;  in  epileptiform  neuralgia, 
18,  19,  26,  48. 

Tumours  involving  Gasserian  ganglion,  of,  31,  33. 
Paralysis,  oculo-motor,  31,  35,  118-I19. 
Paravicini,  cited,  51. 
Pars  intermedia  of  Wrisberg,  107. 
Pepper's  "  System  of  Medicine,"  3. 
Pericranial  gummata,  8. 
Pericranium,  71  ;  danger  of  separation  of,  in  osteoplastic  method  of  removing 

Gasserian  ganglion,  92  and  note". 
Peridental  abscess,  I. 

Periosteum,  62.  ^ 

Periostitis  in  tertiary  syphilis,  headache  from,  8.  « 

Petrous  bone : 

Cholesteatoma  of,  36. 

Tumours  involving,  36,  37. 
Pierret,  cited,  12  and  note. 
Pitts,  Mr.,  47. 

Pituitary  fossa,  tumour  involving,  37. 
Plexiform  sarcoma,  case  of,  35. 
Poirier,  M.  : 

Excision  of  Gasserian  ganglion — method,  90  and  note,  loi. 

Intracranial  excision  of  superior  maxillary  nerve — method,   e,"]  and  note, 
58,  65. 
Policlinico,  II,  cited,  43  note^. 
Potassium,  iodide  of,  14. 
Practitioner,  The,  cited,  102  not^, 
Preglenoid  tubercle  on  the  zygoma,  82. 
Presbyopia,  3. 


149 

Pterygoid  muscles  : 

Paralysis  of,  after  excision  of  ganglion,  io6. 

Relation  of  external  muscle  in  excising  Gasserian  ganglion,  89,  90. 
Pterygo-maxillary  fossa,  excision  of  superior  maxillary  nerve  in,  see  superior 

maxillary  nerve. 
Ptosis  following  total  extirpation  of  Gasserian  ganglion,  118. 

QuENU's  operation,  88. 

Quinine,  administration  of,  in  minor  neuralgia,  14. 

« 
Ransohoff,  J.,  case  of,  cited,  115. 
Raum,  J.,  cited,  92  note^. 
Refraction,  pain  due  to  errors  of,  i. 
Retractors,  79,  80,  116-117. 
Renton,  Dr.  J.  C,  cited,  29,  68  and  nole^. 
Revue  de  Chir.,  cited,  no. 

Rheumatic  tendency,  relation  to  epileptiform  neuralgia,  24. 
Rontgen  Rays,  in  the  treatment  of  epileptiform  neuralgia,  39. 
Rose,  Prof.  Wm.  : 

Pterygoid  method  of  excising  Gasserian  ganglion,  75,  81,  89,  loo-ioi. 

Resection  of  maxillary  nerves  advocated  by,  102  and  note. 

Salomoni,  cited,  121. 

Sapersko's  method  of  removing  Gasserian  ganglion,  88. 

Sclerosis  of  descending  spinal  root  of  fifth  nerve,  12. 

Schorstein,  Dr.  G.,  6. 

Schwab,  cited,  29. 

Sella  turcica,  32. 

Sensation,  impairment  of,  see  Anaesthesia. 

Sensory  root  of  Gasserian  ganglion,  division  of,  97-98. 

Sepsis,  danger  of,  in  operations  on  Gasserian  ganglion,  87,  114-I16. 

Septic  meningitis,  danger  of  inducing,  through  replacement  of  bone,  92. 

Shock  in  excising  Gasserian  ganglion,  cases  of  fatal  result  from,  114-I16. 

Sinkler,  cited,  23  note. 

Skin  : 

Anaesthesia    of,   after   excision    of    Gasserian   ganglion,    see    Cutaneous 

Anesthesia. 
Application  to,  in  minor  neuralgia,  15-16. 
Skull,  section   of,    in   removing   Gasserian   ganglion  ;    various   methods,  88  ; 

Cushing's  method,  89-90;  Poirier's  method,  90;  osteo-plastic  method, 

91-93  ;  Krause's  method,  93. 
Smith,  R.  W.,  "  Monograph  on  Neuroma,"  quoted,  32  and  note,  35. 
Sodium,  iodide  of,  14. 

Spasm  of  facial  muscles  in  epileptiform  neuralgia,  23. 
Spasmodic  neuralgia  in  limbs  and  trunk,  11. 
Spiller,  cited,  27,  29,  35  note. 
Spiller  and  Frazier,  sensory  root  of  Gasserian  ganglion  divided  by,  97-98. 


150 

Spine  of  Spix,  51. 

Spheno-maxillary  fissure,  62,  63,  65. 

Spheno-temporal  fossa,  tumour  in  right  division  of,  34. 

Sphenoid  bone,  63,  89. 

Sphenoidal  air  sinus,  5,  32. 

Stimson,  L.  A.,  fatal  case  of  excision  of  Gasserian  ganglion  by,  115. 

Storrs'  extra-cranial  operation  on  the  superior  maxillary  nerve,  61-65,  66. 

Strychnia,  injection  of,  85. 

Suicide  induced  by  epileptiform  neuralgia,  20-21. 

Superior  maxillary  nerve  : 

Excision  of,  in  the  pterygo-maxillary  fossa, 
Carnochan's  method,  58-61,  65. 
Mugnai's  method,  65-66. 
Poirier's  method,  57-58,  65. 

Intra-cranial  course,  length  of,  68. 
„  resection  of,  68,  69-70. 

Involvement  of,  in  epileptiform  neuralgia,  21,  22  ;  in  sarcoma  of  Gasserian 
ganglion,  34. 

Resection  of,  74,  102. 

Storrs'  extra-cranial  operation  on,  61-65,  66. 
Supra-orbital  neuralgia,  74. 
Syphilis  : 

Epileptiform  neuralgia,  relation  to,  24. 

Headache  and  neuralgia  due  to,  6,  8-9. 

Tabes  dorsalis  and,  il. 


Tabes  dorsalis,  2,  11-12. 

Taste,  perception  of,  after  removal  of  Gasserian  ganglion,  106-108. 

Teeth  : 

Extraction  of,  injuries  in,  13. 

Stopping  of,  neuralgia  due  to,  13,  22. 

Wisdom,  neuralgia  due  to  crowding  out  of,  13. 
Temporo-sphenoidal  lobe,  37,  71. 
Temporal  bone,  34,  89. 

,,        distribution  of  neuralgia,  4. 
Temporal  fossa  : 

Neuralgia  over,  due  to  syphilitic  gumma,  9. 

Relation  of,  in  Mugnai's  excision  of  superior  maxillary  nerve,  65. 

Trephining  wall  of,  in  excising  superior  maxillary  nerve,  66,  71. 

Vertical  incision  over,  in  gaining  access  to  Gasserian  ganglion,  96. 
Temporal   muscle,    58 ;    section   of,  in   excision  of   Gasserian  ganglion,  90 ; 

paralysis  of,  after  excision  of  Gasserian  ganglion,  106. 
Tenotome,  use  of,  84. 
Thiersch's  forceps,  44,  45,  53. 
Tic  douloureux,  see  Epileptiform  Neuralgia. 
Tiffany,  L.  ^l.,  cited,  113,  116. 


Tobacco,  relation  of,  to  epileptiform  neuralgia,  24. 
Tod,  Mr.  Hunter,  42. 
Tongue  : 

Cancer  of,  57. 

Taste  organs  in,  107. 
Trans.  Amer.  Surg.  Assoc,  cited,  75,  92  noU^,  100  note' . 
Trans.  Philad.  Med.  Soc,  cited,  125, 
Traumatism,  relation  to  epileptiform  neuralgia,  24. 
Trav.  Netir.  Chir.  Chip.,  cited,  90  note. 
Trenel,  cited,  37. 

Trephine,  use  of,  in  excising  Gasserian  ganglion,  81. 
Treves,  Sir  F.,  cited,  47,  58  and  note^,  59,  70,  72. 
Trigeminal  neuralgia,  see  Neuralgia. 
Trousseau,  Prof.,  cited,  18,  24,  39,  42. 
Tumours  involving  Gasserian  ganglion. 

Recorded  cases  of,  31-37  ;  classification  of,  37. 

Section  of,  34-35. 
Tympanic  membrane,  aneesthesia   of  portion  of,  after  excision  of  Gasserian 
ganglion,  105. 

Univ.  of  Pennsylvania  Med.  Bull.,  cited,  no,  118  note^. 
United  States,  prevalence  of  epileptiform  neuralgia  in,  21. 

VAN  Geruchten,  cited,  44  note''-. 

Venous  haemorrhage,  55. 

Vertigo,  98. 

Vidian  nerve,  34. 

Viscera,  pain  referred  to  fifth  nerve  from,  3. 

Wall,  Dr.  R.  C.  B.,  40. 

Weeks,  S.  P.,  cited,  92  note. 
Wells'  forceps,  81. 
Winslow,  R.,  case  of,  cited  121. 
Women,  liability  of,  to  neuralgia,  4. 

Zygoma,  division  of,  in  extirpating  Gasserian.  ganglion,   67,  88-89,  90,  93, 
106  ;  mentioned,  65,  71,  80. 


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